COVID-19’s impact on the heart and cardiovascular system is putting pressure on healthcare delivery as the pandemic marches on.
And not just because of the disease’s impact during infection, but the onset of secondary complications after recovery.
Last week, the Actuaries Institute released data showing an uptick in excess mortality of 12% for the first five months of the year (an increase of 8,500 deaths above expectations), more than half were from COVID-19.
While July and August data were not included in these assessments (they are based on the most recent periodic data released by the Australian Bureau of Statistics), COVID-19 deaths during these months were the highest of the pandemic.
Among excess deaths – those which occur above prediction – not attributed to COVID-19, 650 were due to ischaemic heart disease (coronary heart disease) and 220 to cerebrovascular diseases (such as strokes).
This year, we’ve learnt more about COVID’s hand on the human heart
This assessment comes as little surprise.
In February, a large US study into the long-term impacts of heart-health published in Nature Medicine found the disease could cause heart problems, even long after recovery.
These problems include coronary heart disease and strokes, as well as pericarditis, myocarditis, heart failure, thromboembolic disease, and dysrhythmias.
“This is clearly evidence of long-term heart and vascular damage,” said the paper’s senior author clinical epidemiologist at Washington University (St. Louis, USA) Professor Ziyad Al-Aly.
“Similar things could be happening in the brain and other organs resulting in symptoms characteristic of Long COVID, including brain fog.”
It seems when it comes to matters of the heart, COVID-19 does not discriminate: these issues were found to occur across age and gender groups.
Incidence went deeper, though. Beyond these demographic factors, comorbidities like diabetes, obesity, or kidney disease didn’t seem to influence the likelihood of post-COVID heart issues.
Such was the extensive impact of the novel coronavirus on secondary morbidities, even recovery from a mild infection did not rule out the potential for delayed-onset heart issues.
Those admitted to intensive care saw a 14-fold increase in risk of thrombotic disorders like blood clots, a quadrupling of risk for stroke, and almost 10-times the risk of inflammatory heart disease.
But for those who weren’t hospitalised, a near doubling of the risk of a suite of cardiovascular complications was found.
Back in Australia, the suggestion of COVID-19 being the driver of vascular-related deaths is something the Actuaries analysis suggests could be possible, though it points out the medical community is yet to establish “a causative link” between the virus and a heart attack that occurs months after recovery from infection.
While that causative link is still poorly understood, there is evidence pointing to COVID-19’s ability to go beyond simply being a respiratory infection.
“It has been suggested that direct viral invasion of COVID-19 to cardiac cells causes alteration of multiple cell types in heart tissue, dysregulation of the hormonal, immune and nervous system, and induce subsequent fibrosis and scarring of cardiac tissue,” explains Associate Professor Shariful Islam, who leads the Global Health Research Group at the Institute for Physical Activity and Nutrition at Deakin University.
This could explain the increased risk of potential heart-related conditions being put down to COVID-19.
But Islam also observes another common risk of cardiovascular disease – sedentary behaviour.
Widespread lockdowns and work-from-home arrangements implemented in response to the pandemic may have exacerbated periods of inactivity among individuals across the globe.
“While COVID-19 has been an important factor in increased numbers of cardiovascular diseases globally, this is not the only culprit,” Islam says.
“Our research has shown that during COVID-19, people spent more sedentary time and had less physical activity which might also increase the risks of cardiovascular diseases.”
Even with the potential for reduced physical activity to have a greater effect on heart conditions, a new study published in the European Heart Journal found France’s hard lockdowns may have benefitted some people.
Compared to Germany’s piecemeal approach to lockdown, more French people were shown to have improved cardiovascular health, and a reduction in vascular stiffness, which can cause hypertension.
The pandemic’s hidden heartache
While much attention has focussed on how COVID-19 infection can lead to heart complications, one thing that has flown under the radar is the massive reallocation of medical resources to addressing those admitted to hospital with COVID infection.
That’s pulled resources away from other important medical needs, including providing surgical services to those with pre-existing cardiovascular issues.
In May, assessments of COVID-19’s impact on global cardiac services published in the European Heart Journal found major disruptions brought on by the pandemic had led to those suffering from myocardial infarction (a heart attack) or other cardiovascular issues requiring medical attention avoiding emergency departments, or being unable to get hospital admission. Globally, that impact could be felt for years to come, according to Dr Ramesh Nadarajah, a clinical research fellow at Leeds University.
“Across the globe, there were fewer people attending hospital, fewer people having heart procedures, and there were more people dying,” he said.
“I was shocked and surprised by the extent of the detrimental effect [the pandemic had] on the treatments that we could provide, on the number of people that could attend hospital and in terms of how much excess risk there was of death during the pandemic from cardiovascular disease.”
While the effort to curb the pandemic’s reach in 2021 and comprehensive uptake of the first round of vaccines left Australia in relatively good shape compared to many other nations, the effort to restrict movements and limits on surgeries left a backlog of patients waiting to get heart issues addressed.
This additional to those who need medical attention after developing impaired cardiac function during their infection and those now described as suffering cardiovascular complications well after having COVID-19.
Professor Rajesh Puranik, a consultant cardiologist at Royal Prince Alfred Hospital and clinical professor at the University of Sydney, points out that cardiovascular complications from viral infection is nothing new.
“Prior to COVID, occupying our intensive care beds we would quite commonly have influenza patients come in and have myocarditis and stay in an intensive care environment for very prolonged periods of time,” Puranik says.
“So that [cardiovascular complication] is not new, but we’re just seeing it in a massive volume with a new virus that we have poorly understood up until now.”
Puranik says the time is coming to “flick the switch” back to having hospitals, emergency departments and intensive care units treating the broad spectrum of diseases that are in the community – whether because of COVID-19, or independent of it.
“That will require a huge investment of resources back into the health system,” he says.
“We also need to infuse massive levels of confidence in the community that it is now safe to reengage with your doctors, so that you don’t dismiss minor symptoms, you start to get proper face-to-face checks, that we move away from telehealth.
“We need people interacting again, with the health system, with confidence.”
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