Severe infection with COVID-19 attributes to rapid systematic inflammation, sepsis, and pro-inflammatory cytokine storm, which eventually can cause mulitorgan failure and death. 

Cardiovascular Manifestations of COVID-19 (graphic) 

Viral infections are related to metabolic dysfunction, myocardial inflammation, and sympathetic nervous system activation, which all predispose patients to cardiac arrhythmia. 
In a report of 138 hospitalized COVID-19 patients, 16.7% developed arrhythmias. Arrhythmia was observed in only 7% of those who did not need ICU treatment while 44% of those admitted to the ICU developed arrhythmia. 
Instances of developed arrhythmia include: atrial fibrillation, conduction block, ventricular tachycardia, and ventricular fibrillation. Though more research is needed on the associated manifestations. 

COVID-19 and Cardiac Arrhythmia (irregular heart  rhythm) 

Cardiac injury and acute myocarditis are well-established results of viral infections. In regards to COVID-19, reports of myocyte necrosis and mononuclear cell infiltrates suggests that myocarditis could be important in the occurrence of cardiac injury in patients. Mycarditis has the potential to turn into a conduciton block, tachyarrhythmia, and impairment of left ventricular function. Though the details of these findings are still unclear. 
Clinically, COVID-19 related myocarditis may only manifest as mild chest pain and could be rather indistinguishable from other causes in most patients. Sympotoms of myocarditis in COVID-19 patients usually do not present themselves until 10-14 days after the initial onset of symptoms. Data suggests that the delay in myocardial inflammation has to two with two pathogenic mechanisms. First, 'cytokine storm' promotes subclinical autoimmune myocarditis. Secondly, myocardial damage and/or molecular mimicry "initiate a de Novo autoimmune reaction". 


COVID-19 and Myocarditis 

Endothelial dysfunction is a cardiac condition that is the precursor of atherosclerosis.  It is controlled by the so called "cardiovascular risk factors", and when these risk factors are treated, this condition can be reversed.  Endothelial dysfunction leads to:

- plaque buildup in vascular tissue
- thrombosis
- vasoconstriction
- inflammation
- oxidative stress 
- vascular tissue remodeling

Endothelial dysfunction is a comorbidity of conditions that have been shown to aggravate a SARS-CoV-2, including obesity.  It also causes phenomena that might mechanistically enhance COVID-19.

Endothelial Dysfunction and COVID-19

- Angiotensin-converting enzyme 2 (ACE2), which is a membrane bound aminopeptidase that is highly expressed in the heart and lungs, acts as a receptor for SARS-CoV-2, allowing the virus to enter the cell upon binding
- Binding of the virus to ACE2 can cause alterations of ACE2 signaling pathways, which leads to acute myocardial and lung injury

Mechanism for direct myocardial injury in COVID-19 patients 

"Aortic thrombosis is a rare event that can occur in hypercoagulable state as found in patients with COVID-19. A 58-year-old man presented with COVID-19
respiratory failure and elevated D-dimers (4063 lg/l). Computed tomography scanning showed a floating thrombus in the aortic arch." 


Aortic Thrombosis and COVID-19

COVID-19 may predispose patients to thrombotic disease in both the venous and arterial circulations. This predisposition is caused by:

1. Direct and indirect effects of COVID-19 infection (e.g., severe illness and hypoxia).
2. Adverse interactions between therapies for COVID-19 and antithrombotic drugs (e.g., antiplatelet agents and anticoagulants).
3. Negative impacts on the timely treatment of patients with thrombotic events due to pandemic-related resource allocations and social distancing recommendations.

Predisposing Factors for Thrombotic Disease in COVID-19

- Myocardial injury (injury to the muscular tissue of the heart)
- Myocarditis (inflamed heart muscle tissue)
- Myocardial infarction (heart attack)
- Heart failure
- Dysrhythmias (Irregular heart rhythm)
- Venous thrombosis (blood clotting)
- Aortic thrombosis
- Heart palpitations 
- Chest tightening 
- Endothelial dysfunction
- Systemic inflammation 

Smith College

Michigan State University

University of Michigan - Ann Arbor

Cardiovascular disease is a risk factor for severe COVID-19, and COVID-19 causes cardiovascular complications. 

Cardiovascular Disease and COVID-19

Zheng, Y. Y., Ma, Y. T., Zhang, J. Y., & Xie, X. (2020). COVID-19 and the cardiovascular system. Nature reviews. Cardiology, 17(5), 259–260. https://doi.org/10.1038/s41569-020-0360-5

COVID-19 and the Cardiovascular System

Cardiovascular Disease in COVID-19 Patients by Geographic Location

Angiotensin-converting enzyme 2 (ACE2)is a membrane bound protein that functions as a receptor for SARS-CoV-2. Since ACE2 is found in the lungs and heart, systemic inflammatory response triggered by the virus will target those tissues, leading to damage in myocardial cells. This will lead to an increase in cardiovascular symptoms in COVID-19 patients. 

- RAAS and COVID-19 
- ACE Inhibitors and Angiotensin Receptor Blockers 
- Troponin 

Molecular Underpinnings of COVID-19 and the Cardiovascular System

Cardiovascular Complications & Symptoms Associated with COVID-19

- This paper provides a rough summary of the possible induced injuries caused by the comorbidity of cardiovascular disease and COVID-19
- The paper also details some cardiovascular manifestations of COVID-19 by providing some examples of lasting various cardiovascular conditions that can be brought on by the virus itself
- Some direct injuries caused by the comorbidity include direct myocardial injury, systemic inflammation, altered myocardial demand-supply ratio, plaque rupture and coronary thrombosis, adverse effects to various therapies, and electrolyte imbalances
- The paper also describes that patients with preexisting cardiovascular disease have increased risk of for COVID-19 infection as well as worse overall outcomes compared to non-impaired patients
- The paper also describes how the heightened poorer outcomes may also be due to the fact that many cardiovascular disease comorbid patients are also likely to be comorbid with other illnesses such as diabetes or hypertension which also lead to poorer COVID-19 outcomes
- The cardiovascular manifestations described by the paper include acute myocardial injury, arrhythmias,  as well as a short discussion on long term abnormal lipid metabolisms


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