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As medical experts learn more about COVID-19, they’re finding that it can cause damage beyond the lungs. Cardiologist Paul Cremer, MD, shares what’s known so far about how the inflammation caused by COVID-19 can affect the heart. He also discusses potential long-term impacts of the pandemic and what we can all be doing to keep our hearts healthy.

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How Does COVID-19 Affect the Heart? with Dr. Paul Cremer

Podcast Transcript

Deanna Pogorelc:  Welcome to the Health Essentials podcast, brought to you by Cleveland Clinic. I'm your host, Deanna Pogorelc. As medical experts continue to learn more about COVID-19 every day, they're finding that it's not just a disease that affects the lungs. It appears that COVID-19 can cause damage in other parts of the body too, including the heart. Joining us today is cardiologists Dr. Paul Cremer. He's the associate director of the cardiac intensive care unit here at Cleveland clinic, and he is going to share what we know so far about how COVID-19 can affect the heart. Hi Dr. Cremer, thanks for being here.

Dr. Paul Cremer:  Hi, Deanna, thanks for having me.

Deanna Pogorelc:  For our listeners. Please remember this is for informational purposes only and is not intended to replace your own physician's advice. So Dr. Cremer, we've heard since the start of the pandemic that people with certain medical conditions, including some heart conditions, are at a greater risk for COVID-19. Has that been shown to be true with what we're seeing here in the US? And if so, which conditions are people most at risk?

Dr. Paul Cremer:  Yeah. Thanks for that question, and I think that really gets at a lot of what patients are asking about, "Am I at increased risk?" I think unfortunately, what we have seen is that certain patients with cardiac conditions are in fact at increased risk, and those conditions include patients with high blood pressure, patients with diabetes, patients who are overweight or obese, and also elderly patients. So these are people that need to be particularly cautious when it comes to COVID-19, but really all of us need to be especially vigilant about masking appropriately and maintaining social distancing, because even though certain patients, like I mentioned, are at increased risk for having more serious disease from COVID-19, even patients who are otherwise young and healthy, even though it's less common, we're seeing those patients as well get very, very sick from COVID-19.

Deanna Pogorelc:  What is it about the nature of COVID-19 that makes it particularly dangerous to folks who have chronic conditions?

Dr. Paul Cremer:  Right, and so it really gets at why is it that certain people get really sick with COVID-19? And I think, like everything related to this disease, we're learning more every day, but I think there's a couple of observations worth emphasizing. The first is that in patients with COVID-19 what we're seeing is, especially in the second or third week of illness, certain patients develop an overwhelming inflammatory response, such that the own body's immune system is no longer just attacking the virus, but it starts to attack itself. And that primarily involves the lungs, but can involve other organs such as the kidneys and the heart.

And I think related to that it may be that certain patients, such as people who are older, who have chronic conditions, may be more likely to have this inappropriate inflammatory response where the body attacks itself. But what I think is probably more important is that when this does occur, patients who are older and say, have high blood pressure or have diabetes, or are overweight or obese, they have less reserve to be able to handle and recover from this really high inflammatory state and condition.

Deanna Pogorelc:  So do we know what that kind of inflammation does to the heart, or what kind of specific damage is done from the infection?

Dr. Paul Cremer:  So how does this inflammatory response related to COVID involve the heart? So if we take a step back and we look at patients who are sick enough to be in the hospital with COVID-19, so patients with severe and serious disease, a lot of those patients will have evidence of involvement of the heart with a blood test, and that's something we're calling cardiac injury related to COVID-19. And so it varies by study and which patient population you're looking at, but generally speaking, maybe 10% to 25% of patients will have evidence of cardiac injury in the setting of their serious COVID-19 illness.

And that cardiac injury can result from many different causes. It can be related to the heart muscle just not having enough oxygen, so the heart muscle isn't getting enough oxygen, so that can cause some damage. It can be related to damage to the small vessels of the heart or the lining of the blood vessels of the heart. And in addition, in COVID what we've seen is that a lot of these patients get blood clots, and that can involve the small and the large blood vessels. And finally, COVID can directly cause toxicity to the heart cells, that does occur, but that seems to be a rare manifestation of COVID-19 where the virus is invading the heart muscle cells and causing damage.

But it seems that a lot of these other causes that we've talked about, the decrease in the oxygen, the trouble with the small blood vessels and the blood clotting in the heart, those issues seem to be related or are more common in patients who have this really high inflammatory response. So we're beginning to think that it is really this inappropriate inflammatory response that's related to a lot of the different manifestations you can see in patients that have cardiac injury related to COVID-19.

Deanna Pogorelc:  Do we know if that cardiac injury is permanent, or is there a way that people can manage it?

Dr. Paul Cremer:  Yeah, that's an excellent question, and it's a question now that we're getting from a lot of patients who've recovered from COVID-19. I think at this point we really don't know. What we do know is that if we look with sophisticated testing, such as with cardiac MRI, we can find evidence of inflammation in the heart in a lot of patients who've recovered from COVID-19. But as I mentioned, the more severe presentations of COVID-19 involving the heart, where the heart muscle is severely weakened, where the heart is having difficulty pumping blood to the muscles in the body and the other organs, so that really severe form of myocarditis, of inflammation of the heart, fortunately seems to be uncommon in COVID-19. We do see it, but fortunately it is not occurring in that many patients.

So what a lot of people are asking is, "Well, this inflammation that may be there, that's certainly throughout the body, and you can find evidence sometimes in looking at the blood work, or if you look with imaging-based testing with cardiac MRI, what are the long-term consequences in terms of developing an abnormal heart rhythm, of developing heart failure in the future?" I think at this point we really don't know, and we just need to continue to research those questions. What I would say is that most patients who have either asymptomatic COVID-19 or mild disease, as it relates to the heart, can be expected to have an excellent long-term prognosis in that regard. But there's still a lot of questions that need to be answered.

Deanna Pogorelc:  Absolutely. And I want to go back to, you mentioned blood clots earlier, and I've heard that there's a link between COVID-19 and strokes. Can you talk a little bit about that, and are there other vascular concerns with COVID-19?

Dr. Paul Cremer:  Right. So if we think of COVID-19 and this association between the increased inflammation, we know that blood clotting can also occur in the setting of a heightened inflammatory response. And as we talked about, those blood clots can involve the small blood vessels, the microvasculature, it can involve the larger blood vessels, such as the coronary arteries, the blood vessels on top of the heart, and when you get a blood clot there, that would be what we think of classically as a heart attack, of a myocardial infarction. Again, that can occur in the setting of COVID, but like the more severe heart failure presentation, myocarditis, getting a typical heart attack related to COVID-19 also seems to be uncommon.

But it's important to emphasize, when we talk about the blood vessels on top of the heart, we're talking about the arteries. In addition, you can get blood clots involving the arteries to the brain, and that would cause a stroke. And it does seem that that strokes are more common in the setting of COVID-19. And if we think of the blood vessels, we're talking about the arteries, we should also talk about the veins. And we've also observed that in COVID-19, patients are more likely to get blood clots in the veins, such as in the legs. And those blood clots can migrate and result in blood clots in the blood vessels of the lungs. So when we're talking about COVID-19 and this inflammatory response, we really can see an increased risk for blood clots in small and larger blood vessels, and in arteries as well as veins, and so it's something we very much need to look out for in these patients.

Deanna Pogorelc:  Is it common that a viral illness has this kind of impact on the body and specifically on the heart? Are there others that we know do this, or is this something new that we've never seen before?

Dr. Paul Cremer:  Right. So I think if we think about myocarditis, which is inflammation of the heart, viruses are the most likely cause. So we've known that viruses can cause myocarditis for a long time. And I think the important distinction here is the spectrum of inflammation of the heart of myocarditis. I think we're looking much more closely at the heart with COVID than we have with previous viruses, but that said, we are seeing a lot of inflammation of the heart in COVID-19, I would say more so than has been previously reported with other viruses.

However, if we look at the spectrum of the most severe cases, what we might call a fulminant myocarditis, where the patient comes in with a severely weakened heart that's unable to support the necessary blood supply to the essential organs, with COVID-19 that seems to be fairly uncommon, and maybe less common than other viruses which we're more familiar such as influenza. So I think it's a complicated question, in that does COVID-19, is it more likely to cause inflammation of the heart compared to other viruses? I would say probably yes. Is it as likely to cause the most severe manifestations of myocarditis compared to other viruses? I would say probably no. But those are both tentative answers, and I think as we do more research we'll begin to understand this better in the days and months to come.

Deanna Pogorelc:  So speaking of research, can you talk a little bit about some of the studies that you're doing with specific treatments to prevent this kind of heart and respiratory complications with COVID-19?

Dr. Paul Cremer:  Right. So, so we have one study in particular that's looking at blocking this inappropriate inflammatory response related to COVID-19. And this study is unique in that it requires patients, or we're specifically evaluating patients who have this injury to the heart muscle. So they have cardiac injury, and they have severe COVID-19, so serious enough to be in the hospital or in the intensive care unit. And I think it's worth noting that COVID-19 is primarily a respiratory illness that causes pneumonia, but in some patients it will involve the heart as well, most often as collateral damage, and we think probably mediated through this very high and inappropriate inflammatory response.

So the study we're looking at is to see if we give a medication to decrease that body's inflammatory response, if we're able to get people to improve more quickly. That is, can we get them off of oxygen? Can we get them out of the hospital and back to their normal lives by decreasing this really high inflammatory response that we see in COVID? And often it's that inflammation that causes bystander damage, if you will, to the heart.

Deanna Pogorelc:  I want to ask about some of the potential secondary effects of this pandemic that could possibly affect our collective heart health. And there've been some surveys showing that Americans are facing increased stress during the pandemic. And since stress is a risk factor for some chronic conditions, could this potentially impact our collective heart health over the long term?

Dr. Paul Cremer:  Yes, I think that's a very important topic. That is, what are the long-term consequences from COVID-19 in terms of, one, the stress that it's put us all under, and two, the impact it's had on our access to healthcare for our chronic conditions. So I would say that we know that that stress increases the risk of cardiovascular disease and complications related to cardiovascular disease. And it's incredibly difficult during this pandemic, but I think people really need to be doing, we all need to be doing as much as we can to take care of our mental health.

And I think for us in cardiovascular medicine that also involves physical activity. People have been hesitant to exercise, and maybe haven't had the access to exercise, but I think that's great for our mental health and for our cardiovascular health. And in general, we recommend that people try and exercise for at least 150 minutes a week. So that's about 30 minutes of moderate intensity aerobic exercise most days of the week. And I think trying to develop a routine where you're doing that will certainly help with stress, and mental health, and overall cardiovascular health.

And I think the second point in terms of access to care, well, I'd say that when I was in the intensive care unit last month, we had patients who were presenting later in their illness with more advanced disease. And I think the reasons for that are multiple. For one, I think we have to be wary that not all symptoms are related to COVID. So if patients are getting chest pain or shortness of breath, these would be concerning cardiac symptoms, and I think patients may be inclined to think, "Oh, maybe this is COVID, I'm just going to stay home and sit this out." So I really would encourage patients, if you're having those kinds of concerning symptoms such as trouble with your breathing or any discomfort in your chest, that you do see care and try and figure out what's going on.

And second, I would say that patients for a time were hesitant to come into the hospital and were hesitant to seek the care that was needed. So I think they were sort of putting off necessary treatments and tests for their heart condition, and I'm worried that I think that will have a very big longterm impact in terms of public health. So I think it's very important that with the appropriate measures in place, which we have here at the Cleveland Clinic, that patients continue to seek the necessary care for their high blood pressure, their high cholesterol, their coronary disease, their diabetes, because taking care of those conditions now will have a benefit on the overall quality of life and longevity for the decades to come.

Deanna Pogorelc:  Can you speak a little bit to what the condition that we know as broken heart syndrome, and what that is, and whether you've seen more of that in the hospital during the pandemic?

Dr. Paul Cremer:  Yeah, so broken heart syndrome is where the heart becomes acutely weakened and that can result primarily in heart failure. And we know that broken heart syndrome occurs oftentimes in the setting of emotional and physical stress, and we've all been under tremendous emotional and physical stress during the pandemic. And some investigators at the Cleveland Clinic, and also at Akron General, did look and see, given all the stress that we're under, is broken heart syndrome more common during COVID-19 than in other times? And in fact, it seems like it is, and it seems like it's several fold more common, this broken heart syndrome where patients get an acute weakening in their heart muscle.

Now fortunately, with appropriate treatment most patients will have recovery of this weakened heart muscle, but it's an important point to be aware of. And again, just speaks to the trying times we're all having during this pandemic. And one of the risks to the heart that may not be caused by COVID-19, but is a result of all the stress we're under because of COVID-19. Though I would add to that COVID-19 in and of itself can also rarely cause this broken heart syndrome, or stress cardiomyopathy.

Deanna Pogorelc:  Okay. And I think you touched on this a little bit earlier, but what are some of the best things that we can all be doing to protect our hearts during this stressful and as you said, emotionally and physically stressful time?

Dr. Paul Cremer:  Right? So I think that the best things that we can do to protect our hearts during this time is what we should be doing anyway. And it's become more challenging in the setting of the pandemic, but we need to try and continue to take care of our bodies. So what does that mean? Well, that means as we talked about, exercising, so moderate intensity aerobic exercise for up to 150 minutes a week. A good diet, in general we recommend a Mediterranean diet or something with a lot of whole grains and vegetables and less meat. And we need to continue to take care of our chronic cardiac conditions and make sure we're not neglecting our high blood pressure, or high cholesterol, or evaluation for our coronary artery disease because of COVID-19. So I think it's really important that we continue to live healthy lifestyles and maintain optimal control of our chronic conditions during this difficult time.

Deanna Pogorelc:  Well thank you, Dr. Cremer, for being here today. And if you'd like to schedule an appointment with Cleveland Clinic's Heart, Vascular and Thoracic Institute, please call +1 800-659-7822. To listen to more interviews with our heart and vascular experts, check out the Love Your Heart podcast at clevelandclinic.org/loveyourheartpodcast, or subscribe wherever you get your podcasts. And for more health tips, news, and information, follow us at Cleveland Clinic on Facebook, Twitter, and Instagram. Thanks for joining us.

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