Inflammation a culprit in long COVID heart problems

While COVID has long held many mysteries, the researchers found evidence of the heart symptoms common in these patients that suggested ongoing inflammation as a mediator.

In a cohort of 346 previously healthy patients with initially mild COVID-19, most seen because of persistent symptoms a median of about 4 months later, structural heart disease and elevated biomarkers of heart injury or dysfunction were rare.

But there were many signs of subclinical heart problems, reported Valentina O. Puntmann, MD, PhD, of the University Hospital Frankfurt in Germany, and colleagues in naturopathy.

Compared to uninfected controls, the COVID patients had significantly higher diastolic blood pressure and more non-ischemic myocardial scars from late gadolinium enhancement, detectable pericardial effusion without hemodynamic relevance, and pericardial enhancement from gadolinium contrast uptake in the pericardial layers (all P<0.001).

In addition, the 73% of COVID patients examined with cardiac symptoms had higher mapping scores indicating diffuse myocardial inflammation and greater accumulation of pericardial contrast agent on cardiac MR imaging (CMR) than asymptomatic individuals.

“What we’re seeing is relatively mild,” Puntmann said MedPage today. “These are patients who were previously normal.”

The results provided insight into a different group than those often considered for heart problems from COVID-19, as patients with pre-existing heart problems are more likely to end up in the hospital and have serious illnesses and consequences.

Puntmann’s group has been studying people with no prior heart problems to try to self-assess the impact of COVID-19 by using research-grade CMR imaging on patients identified via promotional materials circulated online about GPs, public health officials and patients Clinic groups and websites were recruited.

Although this is a select group of patients that may not be representative of mild COVID-19 cases overall, these patients looking for answers to their symptoms aren’t that uncommon either, Puntmann noted.

Federal survey data suggests that 19% of US adults who had contracted COVID had symptoms that lasted 3 months or more after infection. In the current study, follow-up scans a median of about 11 months after COVID-19 diagnosis showed ongoing cardiac symptoms in 57% of participants. These persistently symptomatic patients had more diffuse diffuse myocardial edema than those who recovered or never had symptoms (native T2 37.9 vs. 37.4 and 37.5 ms, P=0.04).

“The heart involvement is an important part of the long COVID presentation – so the shortness of breath, the exercise intolerance, tachycardia,” Puntmann said in an interview.

Her group concluded that the observed cardiac symptoms “are related to subclinical inflammatory cardiac involvement, which may at least partially explain the pathophysiological background of persistent cardiac symptoms. In particular, severe myocardial injury or structural heart disease are not a prerequisite for the presence of symptoms that contradict classical definitions of viral myocarditis.”

One important clinical implication was pointed out by cardiologist and long-time COVID patient Alice A. Perlowski, MD tweeted: “This study shows how traditional biomarkers (in this case CRP, troponin, NT-proBNP) in #LongCovid probably do NOT tell the whole story. I hope that all clinicians who see these patients in their offices can take this important point with them.”

Among the 346 adults with COVID-19 (mean age 43.3 years, 52% female) assessed at a single center from April 2020 to October 2021, the most common cardiac symptoms were exertional dyspnea (62%) and palpitations (28%). , atypical chest pain (27%) and syncope (3%).

“Understanding what’s going on in a routine cardiac exam is a problem because it’s very difficult to catch what’s very abnormal,” Puntmann said. “That’s partly because of the pathophysiology behind it. … Even if their function is impaired, it will not be so dramatic, because they compensate for this with tachycardia and also a very excited heart function. We don’t see it that way yet, they’re in the decompensation stage.”

The group plans to follow these patients longer term to see what the possible clinical consequences might be, with concern, as stated on the center’s website, that this “could herald a significant burden of heart failure in a few years’ time”. The group is also initiating the placebo-controlled MYOFLAME-19 trial to test anti-inflammatory and renin-angiotensin system-targeting drugs for this population.

Their study only included patients with no prior history of cardiac disease, comorbidities, or abnormal pulmonary function tests at baseline and who had never been hospitalized for acute COVID-19.

Another 95 patients from the clinics with no prior COVID-19 and no known cardiac disease or comorbidities were used as a control group. While the researchers acknowledged there may have been unrecognized differences compared to the COVID patients, they found a similar distribution for age, gender, and cardiovascular risk factors.

Of the COVID patients with symptoms, most were mild or moderate (38% and 33%, respectively), and only nine (3%) had severe symptoms that limited activities of daily living.

Factors that independently predicted cardiac symptoms persisting at least 4 months later (median 329 days after diagnosis) from baseline scan to repeat scan were female gender and diffuse myocardial involvement at baseline imaging.

“Specifically, because our study focused on a select population of individuals with prior COVID illness, it does not provide information on the prevalence of post-COVID cardiac symptoms,” Puntmann’s group wrote. “However, it provides important insights into their spectrum and subsequent development.”