Perel P, Grobbee DE. The Heart in the Time of
. 2020; 15(1): 24.
The Heart in the Time of the ‘Coronavirus’
Pablo Perel1 and Diederick E. Grobbee2
1 Centre for Global Chronic Conditions, London School of Hygiene and Tropical Medicine, London, UK
2 Julius Global Health, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, NL
Corresponding author: Pablo Perel (Pablo.Perel@worldheart.org)
Keywords: Cardiology; Coronavirus
We are living in extra-ordinary times. The coronavirus disease 19 (COVID-19) pandemic which started in
December in China, which has spread around the globe and, as of March 16th 167,511 cases in 152 countries
have been reported, and 6,606 related deaths [1, 2]. The response is unprecedented and is affecting every-
one’s life. It will undoubtedly be a memorable time for many generations.
In parallel to the exponential increase in cases of Covid-19 there is also an epidemic of information, data,
opinion, and editorials in both medical journals and social media. As of March 16th, there are 1,766 papers on
the WHO database on Global Research on COVID-19 published in 2020, which means an average of 23 papers
per day . Only on March 11th there were 19 million mentions to COVID-19 in social media . It is indeed
very challenging to discern, in this frantic and dynamic situation, the signal from the noise.
There are a few issues for which there is some consensus: the transmissibility and severity is higher than
seasonal flu, the pandemic will likely affect every country around the globe, governments need to implement
policy and health system country wide actions (although the exact nature of these actions is still a matter
of hot debates), and people with pre-existing chronic conditions including cardiovascular disease, hyperten-
sion and diabetes appear to be at a higher risk of developing complications and, therefore, at a higher risk of
death. As part of the scientific cardiovascular community, we are particularly interested in this latter issue.
Previous studies have shown that people with cardiovascular disease who experienced an acute infection
due to other viruses, such as influenza, are at higher risks of cardiovascular events . Also, during previ-
ous coronavirus epidemics, such as the one by the Middle East Respiratory Syndrome (MERS), an associa-
tion between cardiac disease has been described, and specifically there were case reports of MERS related
myocarditis [6, 7].
The information on the current COVID-19 pandemic is scattered and incomplete. Some studies, mainly
from China, have shown that COVID-19 patients have a high prevalence of cardiovascular disease, hyper-
tension and diabetes, but how much this is due to the epidemiological characteristics of the population
at risk of COVID-19 (elderly) and how much is due to a specific risk associated with these conditions is not
clear [8, 9]. Also, some small studies have shown that patients with cardiovascular disease are at a higher
risk of complications, such as myocarditis and myocardial infarction, but what are the most frequent car-
diovascular complications and which are the patients with cardiovascular disease at a higher risk remain
unknown . The information on management strategies for patients with cardiovascular disease and
COVID-19 is also limited, one of the most debated topics is the relationship between the angiotensin- con-
verting enzyme 2 (ACE2) and COVID-19. ACE2 has a vital role in the cardiovascular systems and has been
also identified as a functional receptor for coronaviruses (infection is triggered by binding of the spike
protein of the virus to ACE2) . There have been publications (mainly letters) suggesting a deleterious (or
beneficial) effect of ACE inhibitor or angiotensin-receptor blocker on patients with COVID-19, but these are
mainly theories [12, 13]. Since research is lacking, several international organizations have released state-
ments highlighting the lack of evidence for any harmful effect and asking physicians not to change clinical
practice based on this hypothesis [14–16].
Current studies are limited in their design (e.g. small numbers, limited geographical representation, lack
of data standardization for risk factors and outcomes, limited measurement of confounders, and missing
data among other limitations) and therefore is difficult to reach robust conclusions. Some examples of
Perel and Grobbee: The Heart in the Time of the ‘Coronavirus’Art. 24, page 2 of 3
relevant research studies we should be conducting include a better understanding of the cardiovascular
conditions that increase the risk of developing COVID-19, better characterization of cardiovascular com-
plications in patients with COVID-19 (e.g. myocarditis), developing simple risk scores to identify patients
at high risk of complications to inform triage at the clinical front line, and testing specific treatments and
strategies to reduce cardiovascular complications.
Global Heart is therefore inviting researchers across the globe to submit papers related to CVD and
COVID-19. We particularly welcome results based on data in low-resource settings.
Also, and in order to help the cardiovascular community to cope with the rapid and emerging evidence
we are initiating the Global Heart & COVID-19 blog in which we will summarize and comment on the most
important articles published on this topic in all journals.
We know it is a very challenging context to conduct research, but we need to try our best to obtain more
and better data. In these difficult times, when the foundation of globalization is being challenged, we also
need to show the value of collaboration: we encourage sharing protocols, learning from each other and
building global collaborations so there are comparable data across the globe.
As part of the cardiovascular community, we are committed to improving the evidence, as much as pos-
sible, to inform the care of the hundreds of thousands (if not millions) of people who will be affected by
The authors have no competing interests to declare.
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COVID-19 in Wuhan, China: A retrospective cohort study. Lancet. 2020. https://www.thelancet.com/
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Perel and Grobbee: The Heart in the Time of the ‘Coronavirus’ Art. 24, page 3 of 3
How to cite this article: Perel P, Grobbee DE. The Heart in the Time of the ‘Coronavirus’.
15(1): 24. DOI: https://doi.org/10.5334/gh.786
Submitted: 18 March 2020 Accepted: 18 March 2020 Published: 24 March 2020
Copyright: © 2020 The Author(s). This is an open-access article distributed under the terms of the Creative Commons
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