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The Heart in the Time of the ‘Coronavirus’

Perel P, Grobbee DE. The Heart in the Time of
the ‘Coronavirus’.
Global Heart
. 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 (
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 [3]. Only on March 11th there were 19 million mentions to COVID-19 in social media [4]. 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 [5]. 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 [10]. 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) [11]. 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
Competing Interests
The authors have no competing interests to declare.
1. Thienemann F, Pinto F, Grobbee DE, Boehm M, Bazargani N, Ge J, et al. World Heart Federa-
tion Briefing on Prevention: Coronavirus Disease 2019 (COVID-19) in low-income countries. Global
Heart. 2020; 15(1): 23. DOI:
2. WHO. Coronavirus disease 2019 (COVID-19) situation report—56. March 16, 2020. https://www.
3. WHO. Global research on coronavirus disease (COVID-19). Database of publications on coronavirus
disease (COVID-19).
4. Managing Brand Communication During Covid-19. Published March 12th at https://blog.sprinklr.
5. Smeeth L, Thomas SL, Hall AJ, Hubbard R, Farrington P, Vallance P. Risk of myocardial infarc-
tion and stroke after acute infection or vaccination. N Engl J Med. 2004; 351(25): 2611–8. DOI:
6. Alsaha AJ, Cheng AC. The epidemiology of Middle East respiratory syndrome coronavirus in the
Kingdom of Saudi Arabia, 2012–2015. Int J Infect Dis. 2016; 45: 1–4. DOI:
7. Alhogbani T. Acute myocarditis associated with novel Middle East respiratory syndrome coronavi-
rus. Ann. Saudi Med. 2016; 36: 78–80. DOI:
8. Li B, Yang J, Zhao F, et al. Prevalence and impact of cardiovascular metabolic diseases on COVID-19 in
China. Clin Res Cardiol. 2020. DOI:
9. Zhou F, Yu T, Du R, et al. Clinical course and risk factors for mortality of adult inpatients with
COVID-19 in Wuhan, China: A retrospective cohort study. Lancet. 2020.
journals/lancet/article/PIIS0140-6736(20)30566-3/fulltext. DOI:
10. Hui H, Zhang Y, Yang X, Wang X, He B, Li L, Li H, Tian J, Chen Y. Clinical and radiographic features
of cardiac injury in patients with 2019 novel coronavirus pneumonia. medRvix. 2020. DOI: https://doi.
11. Zheng Y, Ma Y, Zhang J, et al. COVID-19 and the cardiovascular system. Nat Rev Cardiol. 2020. DOI:
12. Fang L, Karakiulakis G, Roth M. Are patients with hypertension and diabetes mellitus at increased
risk for COVID-19 infection? Lancet Respir Med. 2020. (March 11, 2020). DOI:
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’.
Global Heart
. 2020;
15(1): 24. DOI:
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
Attribution 4.0 International License (CC-BY 4.0), which permits unrestricted use, distribution, and reproduction in any
medium, provided the original author and source are credited. See
Global Heart
is a peer-reviewed open access journal published by Ubiquity Press. OPEN ACCESS
... Other patients may present with severe cardiomyopathy and normal coronaries (Takotsubo-like syndrome). Some patients might suffer from side effects of COVID-19 treatment like hydroxychloroquine-azithromycin combination which might cause fatal prolonged QT interval [4][5][6][7][8]. These patients should be investigated as follows: CBC, ESR, CRP, D dimers, cardiac troponin, ECG (to assess ischemia, arrhythmia, and QT interval), CXR (to assess signs of cardiomegaly or pneumonia), echocardiography (to assess LV diastolic dysfunction, LVEF, valvular lesions, and pericardial effusion), coronary angiography if indicated, PCR to nasopharyngeal swabs and CT chest. ...
... These patients should be investigated as follows: CBC, ESR, CRP, D dimers, cardiac troponin, ECG (to assess ischemia, arrhythmia, and QT interval), CXR (to assess signs of cardiomegaly or pneumonia), echocardiography (to assess LV diastolic dysfunction, LVEF, valvular lesions, and pericardial effusion), coronary angiography if indicated, PCR to nasopharyngeal swabs and CT chest. (Table 1 and Table 2) Most cardiac drugs, such as antiplatelets, statins, and RAS blockers can be safely continued after the diagnosis of COVID-19 [4][5][6][7][8]. ...
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COVID-19 pandemic poses an enormous challenge to healthcare system in Egypt. This document is a position statement from the Egyptian Society of Cardiology. It aims to provide information to cardiovascular healthcare providers in Egypt to guarantee delivery of quality patient care and ensure adequate levels of protection against infection during the COVID-19 pandemic. Older patients and those with cardiovascular disease are at higher risk of mortality. The current situation requires unusual allocation of resources which may negatively impact the care of patients with cardiovascular disease. Cardiologists should be prepared in the COVID-19 pandemic. The challenge is in providing the best quality of care despite limited resources while keeping all medical staff as safe as possible. Consider deferring elective procedures whenever possible. All medical staff should undergo rigorous training on infection control and the use of high-quality personal protection equipment. Cardiologists should promote telemedicine in the outpatient setting, prioritize outpatient contacts, and avoid nosocomial dissemination of the virus to patients and healthcare providers. A much conservative approach for emergent cardiac patients is recommended, and invasive interventions are reserved for high risk hemodynamically unstable patients. During the pandemic, the most important principles of treatment should be controlling the spread of infection as the first priority, prompt assessment of patient risk, recommending conservative medical therapy rather than invasive interventions, and strict infection control measures to limit infection spread within the hospital and to healthcare workers.
... Coronavirus disease-2019 (COVID-19), caused by SARS-CoV-2, has been declared a global pandemic, (1) and numbers of new cases increase daily in Africa (Table 1 for abbreviations). (2) From limited data, SARS-CoV-2 involves the cardiovascular system in multiple ways. ...
Background: The novel coronavirus disease-2019 (COVID-19) spread rapidly around the world and was declared as the second pandemic of the 21st century. The first case was detected in Qatar on February 29, 2020. In order to protect patients and staff in Heart Hospital, the only tertiary cardiac center in Qatar, new measures were implemented to reduce the spread of infection in our hospital. Methodology: A 13-bed high dependency isolation unit was allocated to receive cardiac patients with appreciate infection control measures. Another isolation unit was also established in coronary care unit for critical patients. All patients admitted to Heart Hospital were tested for COVID-19 on admission. Patients were transferred out of isolation, if result was negative. Patients with positive results were either transferred to a COVID facility before or after planned cardiac procedure depending on their cardiovascular disease risk. Results: Six hundred and seven patients were admitted to both the isolation units, most of them were men (89%). Forty-four percent were diagnosed with ST elevation myocardial infarction, 22% were non-STEMI or unstable angina, 17% were decompensated heart failure, 7% were elective cases for coronary angiography or electrophysiology procedures, 8% for other diagnosis, and 1% for both cardiac arrest and post cardiac surgery. 85.2% of the patients admitted to isolation units were tested negative and transferred to normal wards to complete their treatment. Eighty percent of the patients tested positive or reactive for COVID-19 had epidemiological risk, 8.4% had suggestive symptoms, and 11.6% had abnormal chest X-ray. Conclusion: This study demonstrated the importance of the isolation unit with infection control measures in controlling the transmission of COVID-19 in a hospital setting such as the Heart Hospital. Epidemiological risk factors including recent travel, close contact with suspected or confirmed cases within 14 days or less, living in shared accommodation or living in lockdown area were the main risk factors for spreading COVID-19 infection which can be managed by minimizing social activities.
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Background Studies have reminded that cardiovascular metabolic comorbidities made patients more susceptible to suffer 2019 novel corona virus (2019-nCoV) disease (COVID-19), and exacerbated the infection. The aim of this analysis is to determine the association of cardiovascular metabolic diseases with the development of COVID-19.MethodsA meta-analysis of eligible studies that summarized the prevalence of cardiovascular metabolic diseases in COVID-19 and compared the incidences of the comorbidities in ICU/severe and non-ICU/severe patients was performed. Embase and PubMed were searched for relevant studies.ResultsA total of six studies with 1527 patients were included in this analysis. The proportions of hypertension, cardia-cerebrovascular disease and diabetes in patients with COVID-19 were 17.1%, 16.4% and 9.7%, respectively. The incidences of hypertension, cardia-cerebrovascular diseases and diabetes were about twofolds, threefolds and twofolds, respectively, higher in ICU/severe cases than in their non-ICU/severe counterparts. At least 8.0% patients with COVID-19 suffered the acute cardiac injury. The incidence of acute cardiac injury was about 13 folds higher in ICU/severe patients compared with the non-ICU/severe patients.Conclusion Patients with previous cardiovascular metabolic diseases may face a greater risk of developing into the severe condition and the comorbidities can also greatly affect the prognosis of the COVID-19. On the other hand, COVID-19 can, in turn, aggravate the damage to the heart.
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In December 2019, the novel coronavirus Coronavirus Disease 2019 (COVID-19) outbreak started in Wuhan, the capital of Hubei province in China. Since then it has spread to many other regions, including low-income countries. Publisher's note: Due to the pressing nature of this report, we are offering a preliminary version of it while the final version of the manuscript is in editing. As soon as the final version is ready, this will be updated accordingly.
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Objective: To investigate the correlation between clinical characteristics and cardiac injury of COVID-2019 pneumonia. Methods: In this retrospective, single-center study, 41 consecutive corona virus disease 2019 (COVID-2019) patients (including 2 deaths) of COVID-2019 in Beijing Youan Hospital, China Jan 21 to Feb 03, 2020, were involved in this study. The high risk factors of cardiac injury in different COVID-2019 patients were analyzed. Computed tomographic (CT) imaging of epicardial adipose tissue (EAT) has been used to demonstrate the cardiac inflammation of COVID-2019. Results:Of the 41 COVID-2019 patients, 2 (4.88%), 32 (78.05%), 4 (9.75%) and 3 (7.32%) patients were clinically diagnosed as light, mild, severe and critical cases, according to the 6th guidance issued by the National Health Commission of China. 10 (24.4%) patients had underlying complications, such as hypertension, CAD, type 2 diabetes mellites and tumor. The peak value of TnI in critical patients is 40-fold more than normal value. 2 patients in the critical group had the onset of atrial fibrillation, and the peak heart rates reached up to 160 bpm. CT scan showed low EAT density in severe and critical patients. Conclusion: Our results indicated that cardiac injury of COVID-2019 was rare in light and mild patients, while common in severe and critical patients. Therefore, the monitoring of the heart functions of COVID-2019 patients and applying potential interventions for those with abnormal cardiac injury related characteristics, is vital to prevent the fatality.
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The novel Middle east respiratory syndrome coronavirus (MeRS-CoV) has been identified as a cause of pneumonia; however, it has not been reported as a cause of acute myocarditis. A 60-year-old man presented with pneumonia and congestive heart failure. On the first day of admission, he was found to have an elevated troponin-l level and severe global left ventricular systolic dysfunction on echo-cardiography. The serum creatinine level was found mildly elevated. Chest radiography revealed in the lower lung fields accentuated bronchovascular lung markings and multiple small patchy opacities. Laboratory tests were negative for viruses known to cause myocarditis. Sputum sample was positive for MeRS-CoV. Cardiovascular magnetic resonance revealed evidence of acute myocarditis. the patient had all criteria specified by the international Consensus Group on CMR in Myocarditis that make a clinical suspicion for acute myocarditis. this was the first case that demonstrated that MeRS-CoV may cause acute myocarditis and acute-onset heart failure.
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Objectives: The aim of this study was to review the epidemiology of cases of Middle East respiratory syndrome coronavirus (MERS-CoV) reported in the Kingdom of Saudi Arabia from 2012 when the first MERS-CoV was confirmed up to July 2015. Methods: MERS-CoV data were obtained from the Saudi Ministry of Health for the period 2012 to July 2015. Descriptive statistics were used to summarize the results regarding the risk factors and mortality of MERS-CoV infection. Results: In this series, the risk factors and outcomes of 939 cases of MERS-CoV occurring in the last 3 years are described. The majority of the affected patients were aged ≥40 years (n = 657; 70%). Of the 657 patients aged ≥40 years, 377 (57.3%) died. Conclusions: The case-fatality ratio was found to increase significantly with age. It ranged from 12.5% in those aged ≤19 years to 86.2% in those aged ≥80 years. The results confirmed the association between severe MERS-CoV illness and patients with a pre-existing health morbidity. The duration from symptom onset to admission was not statistically associated with the disease outcome.
Background Since December, 2019, Wuhan, China, has experienced an outbreak of coronavirus disease 2019 (COVID-19), caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Epidemiological and clinical characteristics of patients with COVID-19 have been reported but risk factors for mortality and a detailed clinical course of illness, including viral shedding, have not been well described. Methods In this retrospective, multicentre cohort study, we included all adult inpatients (≥18 years old) with laboratory-confirmed COVID-19 from Jinyintan Hospital and Wuhan Pulmonary Hospital (Wuhan, China) who had been discharged or had died by Jan 31, 2020. Demographic, clinical, treatment, and laboratory data, including serial samples for viral RNA detection, were extracted from electronic medical records and compared between survivors and non-survivors. We used univariable and multivariable logistic regression methods to explore the risk factors associated with in-hospital death. Findings 191 patients (135 from Jinyintan Hospital and 56 from Wuhan Pulmonary Hospital) were included in this study, of whom 137 were discharged and 54 died in hospital. 91 (48%) patients had a comorbidity, with hypertension being the most common (58 [30%] patients), followed by diabetes (36 [19%] patients) and coronary heart disease (15 [8%] patients). Multivariable regression showed increasing odds of in-hospital death associated with older age (odds ratio 1·10, 95% CI 1·03–1·17, per year increase; p=0·0043), higher Sequential Organ Failure Assessment (SOFA) score (5·65, 2·61–12·23; p<0·0001), and d-dimer greater than 1 μg/L (18·42, 2·64–128·55; p=0·0033) on admission. Median duration of viral shedding was 20·0 days (IQR 17·0–24·0) in survivors, but SARS-CoV-2 was detectable until death in non-survivors. The longest observed duration of viral shedding in survivors was 37 days. Interpretation The potential risk factors of older age, high SOFA score, and d-dimer greater than 1 μg/L could help clinicians to identify patients with poor prognosis at an early stage. Prolonged viral shedding provides the rationale for a strategy of isolation of infected patients and optimal antiviral interventions in the future. Funding Chinese Academy of Medical Sciences Innovation Fund for Medical Sciences; National Science Grant for Distinguished Young Scholars; National Key Research and Development Program of China; The Beijing Science and Technology Project; and Major Projects of National Science and Technology on New Drug Creation and Development.
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infects host cells through ACE2 receptors, leading to coronavirus disease (COVID-19)-related pneumonia, while also causing acute myocardial injury and chronic damage to the cardiovascular system. Therefore, particular attention should be given to cardiovascular protection during treatment for COVID-19.
There is evidence that chronic inflammation may promote atherosclerotic disease. We tested the hypothesis that acute infection and vaccination increase the short-term risk of vascular events. We undertook within-person comparisons, using the case-series method, to study the risks of myocardial infarction and stroke after common vaccinations and naturally occurring infections. The study was based on the United Kingdom General Practice Research Database, which contains computerized medical records of more than 5 million patients. A total of 20,486 persons with a first myocardial infarction and 19,063 persons with a first stroke who received influenza vaccine were included in the analysis. There was no increase in the risk of myocardial infarction or stroke in the period after influenza, tetanus, or pneumococcal vaccination. However, the risks of both events were substantially higher after a diagnosis of systemic respiratory tract infection and were highest during the first three days (incidence ratio for myocardial infarction, 4.95; 95 percent confidence interval, 4.43 to 5.53; incidence ratio for stroke, 3.19; 95 percent confidence interval, 2.81 to 3.62). The risks then gradually fell during the following weeks. The risks were raised significantly but to a lesser degree after a diagnosis of urinary tract infection. The findings for recurrent myocardial infarctions and stroke were similar to those for first events. Our findings provide support for the concept that acute infections are associated with a transient increase in the risk of vascular events. By contrast, influenza, tetanus, and pneumococcal vaccinations do not produce a detectable increase in the risk of vascular events.