Three Years of COVID-19 Pandemic—Is the Heart Skipping a Beat?

In the context of new therapeutic protocols and vaccines developed in the past 3 years, coronavirus 2019 (COVID-19) continues to exert an important impact on the healthcare systems worldwide. Age and a history of cardiovascular or respiratory diseases remain relevant in terms of prognosis for all COVID-19 patients, independent of the viral strain, by conveying a worse outcome and increased rates of in-hospital mortality. Previous studies reported heterogenous cardiovascular manifestations in COVID-19 patients from acute myocarditis or myopericarditis, acute coronary syndromes, stress cardiomyopathy, de novo arrhythmias to pulmonary embolism, or in some rare cases, endocarditis. In this review, we assessed the potential acute, in-hospital and long-term cardiac complications in patients diagnosed with COVID-19. [ FROM AUTHOR] Copyright of COVID is the property of MDPI and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full . (Copyright applies to all s.)

Expert Consensus for Management of Myocardial Injury, Myocarditis, and Post-infection Condition with Coronavirus Disease 2019 (Second Edition)

Evidence shows that coronavirus disease 2019（COVID-19） can impact multiple bodily systems，with the cardiovascular system being commonly affected. In order to guide healthcare providers in diagnosing and managing cardiovascular issues related to COVID-19，the consensus group recommends：（1）Routine cardiac troponin testing is necessary for patients who are hospitalized or exhibit symptoms related to heart conditions after COVID-19 infection to evaluate potential myocardial injury and help detect any cardiac complications. Patients with myocardial injury not related to heart issues tend to have a poorer outcome. （2）Relatively few cases of acute myocarditis linked to COVID-19 have been reported，and individuals suspected of having myocarditis should be evaluated and managed based on risk stratification. （３）COVID-19 infection should be considered a risk factor for increasing the incidence of cardiovascular disease. All individuals who have been infected should adhere to a healthy lifestyle more strictly and implement appropriate primary or secondary preventive measures for cardiovascular disease.（4）For individuals who experience the persistence or emergence of new symptoms 3 months after the initial COVID-19 infection and have been experiencing these symptoms for at least 2 months，with no clear diagnosis of a cardiovascular disease through standard diagnostic tests，it is advisable to consider the possibility of "post COVID-19 condition". Rehabilitation should be given top priority for these patients. © 2023 Chinese General Practice. All rights reserved.

Expert Consensus for Management of Myocardial Injury, Myocarditis, and Post-infection Condition with Coronavirus Disease 2019 (Second Edition)

Evidence shows that coronavirus disease 2019（COVID-19） can impact multiple bodily systems，with the cardiovascular system being commonly affected. In order to guide healthcare providers in diagnosing and managing cardiovascular issues related to COVID-19，the consensus group recommends：（1）Routine cardiac troponin testing is necessary for patients who are hospitalized or exhibit symptoms related to heart conditions after COVID-19 infection to evaluate potential myocardial injury and help detect any cardiac complications. Patients with myocardial injury not related to heart issues tend to have a poorer outcome. （2）Relatively few cases of acute myocarditis linked to COVID-19 have been reported，and individuals suspected of having myocarditis should be evaluated and managed based on risk stratification. （３）COVID-19 infection should be considered a risk factor for increasing the incidence of cardiovascular disease. All individuals who have been infected should adhere to a healthy lifestyle more strictly and implement appropriate primary or secondary preventive measures for cardiovascular disease.（4）For individuals who experience the persistence or emergence of new symptoms 3 months after the initial COVID-19 infection and have been experiencing these symptoms for at least 2 months，with no clear diagnosis of a cardiovascular disease through standard diagnostic tests，it is advisable to consider the possibility of "post COVID-19 condition". Rehabilitation should be given top priority for these patients. © 2023 Chinese General Practice. All rights reserved.

Prevalence and diagnostic significance of de-novo 12-lead ECG changes after COVID-19 infection in elite soccer players.

BACKGROUND AND AIM: The efficacy of pre-COVID-19 and post-COVID-19 infection 12-lead ECGs for identifying athletes with myopericarditis has never been reported. We aimed to assess the prevalence and significance of de-novo ECG changes following COVID-19 infection. METHODS: In this multicentre observational study, between March 2020 and May 2022, we evaluated consecutive athletes with COVID-19 infection. Athletes exhibiting de-novo ECG changes underwent cardiovascular magnetic resonance (CMR) scans. One club mandated CMR scans for all players (n=30) following COVID-19 infection, despite the absence of cardiac symptoms or de-novo ECG changes. RESULTS: 511 soccer players (median age 21 years, IQR 18-26 years) were included. 17 (3%) athletes demonstrated de-novo ECG changes, which included reduction in T-wave amplitude in the inferior and lateral leads (n=5), inferior leads (n=4) and lateral leads (n=4); inferior T-wave inversion (n=7); and ST-segment depression (n=2). 15 (88%) athletes with de-novo ECG changes revealed evidence of inflammatory cardiac sequelae. All 30 athletes who underwent a mandatory CMR scan had normal findings. Athletes revealing de-novo ECG changes had a higher prevalence of cardiac symptoms (71% vs 12%, p<0.0001) and longer median symptom duration (5 days, IQR 3-10) compared with athletes without de-novo ECG changes (2 days, IQR 1-3, p<0.001). Among athletes without cardiac symptoms, the additional yield of de-novo ECG changes to detect cardiac inflammation was 20%. CONCLUSIONS: 3% of athletes demonstrated de-novo ECG changes post COVID-19 infection, of which 88% were diagnosed with cardiac inflammation. Most affected athletes exhibited cardiac symptoms; however, de-novo ECG changes contributed to a diagnosis of cardiac inflammation in 20% of athletes without cardiac symptoms.

Cardiologic evaluation of Turkish mitochondrial fatty acid oxidation disorders.

BACKGROUND: Mitochondrial fatty acid oxidation disorders (FAODs) cause impairment in energy metabolism and can lead to a spectrum of cardiac pathologies including cardiomyopathy and arrhythmias. The frequency of underlying cardiac pathologies and the response to recommended treatment in FAODs was investigated. METHODS: Sixty-eight children (35 males, 33 females) with the diagnosis of a FAOD were included in the study. Cardiac function was evaluated with 12-lead standard electrocardiography, echocardiography, and 24 h Holter monitoring. RESULTS: Forty-five patients (66%) were diagnosed after disease symptoms developed and 23 patients (34%) were diagnosed in the pre-symptomatic period. Among symptomatic patients (n: 45), cardiovascular findings were detected in 18 (40%) patients, including cardiomyopathy in 14 (31.1%) and conduction abnormalities in 4 (8.8%) patients. Cardiac symptoms were more frequently detected in primary systemic carnitine deficiency (57.1%). Patients with multiple acyl-CoA dehydrogenase, long-chain 3-hydroxyacyl-CoA dehydrogenase, and mitochondrial trifunctional protein deficiencies also had an increased frequency of cardiac symptoms. Patients with medium-chain acyl-CoA dehydrogenase, very long-chain acyl-CoA dehydrogenase, and carnitine palmitoyltransferase I deficiencies had a lower prevalence of cardiac symptoms both during admission and during clinical follow up. Cardiomyopathy resolved completely in 8/14 (57%) patients and partially in 2/14 (14.3%) patients with treatment. Two patients with cardiomyopathy died in the newborn period; cardiomyopathy persisted in 1 (7.1%) patient with very long-chain acyl-CoA dehydrogenase deficiency. CONCLUSION: Early diagnosis, treatment and follow up made a significant contribution to the improvement of cardiac symptoms of patients with FAODs.

Importance of cardiac magnetic resonance imaging in cardiomyopathies in present scenario

Cardiomyopathy includes a heterogeneous group of diseases and conditions that are caused by mechanical and/or electrical dysfunction and shows inappropriate hypertrophy or dilatation which may be due to various causes, mostly genetic, can be confined only to heart or may be a part of systemic disorders. It includes hypertrophic, dilated, arrhythmogenic right ventricular cardiomyopathy, restrictive, and unclassified type. Cardiac magnetic resonance imaging (C-MRI) is currently the gold standard examination due to its high temporal and spatial resolution. In late gadolinium enhancement (LGE) studies, the gadolinium contrast which is administered, it has a slower washout rate in abnormal areas of increased extracellular space and fibrosis. The normal myocardium gets nulled and the abnormal areas are seen as bright areas on LGE. According to the Global Burden of Diseases, injuries, and risk factors study 2016, cardiomyopathy contributed to 0.12% of total deaths, 0.11% of total disability-adjusted life years in India. The main objective of the article is to review the role of MRI in cardiomyopathies (CMPs), especially after post-COVID-19 pandemic with the purpose whether this can be one shop modality with reference to echocardiography. With the advancement in MRI technology and availability of state of art cardiac coils and cardiac software C-MRI has emerged as modality of choice in diagnosis as well as in follow-up cases of CMPs diseases as it is nonoperator dependent as well as radiation-free modality.

Cardiac injury on admission linked to worse outcomes in hospitalized COVID-19 patients

Background/Aim. The novel severe acute respiratory syn-drome coronavirus 2 (SARS Cov-2) has triggered a pandem-ic that causes a disease with complex clinical manifestations (coronavirus disease 2019, COVID-19). Soon it became clear that patients who had some comorbidities had a bigger chance of getting the severe form of COVID-19. The aim of the study was to investigate if there was a link between cardiac injury and COVID-19 severity and mortality in pa-tients. Methods. All consecutive patients with laboratory -confirmed COVID-19 were included and followed up until discharge or death from January 30, 2020, to April 5, 2020. Results. A total of 261 COVID-19 patients were included, and 29 (11.1%) had cardiac injury on admission. Patients with cardiac injury were older than those without cardiac in-jury (72.8 vs 55.8 years old) and more likely to be male (82.8% vs 42.2%). Patients with cardiac injury were also more likely to be smokers (31.0% vs 12.5%), more likely to have chronic cardiovascular disease (24.1% vs 7.8%), chron-ic pulmonary disease (17.2% vs 3.0%), and chronic kidney disease (10.3% vs 2.2%) compared to patients without cardi-ac injury. Laboratory findings suggested that patients with cardiac injury were more likely to have leukocyte counts > 10 x 109/L, pronounced lymphopenia, direct bilirubin, myohemoglobin, blood urea nitrogen, C-reactive protein, and pro-B-type natriuretic peptide but lower levels of se-rum total protein and estimated glomerular filtration rates compared to patients without cardiac injury. Patients with cardiac injury experienced more complications (72.4% vs 47.8%), including acute respiratory distress syndrome (20.7% vs 2.7%), acute kidney injury (10.3 vs 0.4%), severe COVID-19 (58.6% vs 11.6%) and death (55.2% vs 3.9%) compared to patients without cardiac injury. Multivariate analyses showed that cardiac injury was associated with an increased risk of severe COVID-19 [hazard ratio (HR) = 8.71, 95% confidence interval (CI) = 2.37-32.04] and death (HR = 20.84, 95% CI = 1.32-328.22). Conclusion. Cardiac injury on admission was associated with a higher risk of disease progression and death in patients with COVID-19.

Dilated cardiomyopathy in the era of precision medicine: latest concepts and developments.

Dilated cardiomyopathy (DCM) is an umbrella term entailing a wide variety of genetic and non-genetic etiologies, leading to left ventricular systolic dysfunction and dilatation, not explained by abnormal loading conditions or coronary artery disease. The clinical presentation can vary from asymptomatic to heart failure symptoms or sudden cardiac death (SCD) even in previously asymptomatic individuals. In the last 2 decades, there has been striking progress in the understanding of the complex genetic basis of DCM, with the discovery of additional genes and genotype-phenotype correlation studies. Rigorous clinical work-up of DCM patients, meticulous family screening, and the implementation of advanced imaging techniques pave the way for a more efficient and earlier diagnosis as well as more precise indications for implantable cardioverter defibrillator implantation and prevention of SCD. In the era of precision medicine, genotype-directed therapies have started to emerge. In this review, we focus on updates of the genetic background of DCM, characteristic phenotypes caused by recently described pathogenic variants, specific indications for prevention of SCD in those individuals and genotype-directed treatments under development. Finally, the latest developments in distinguishing athletic heart syndrome from subclinical DCM are described.

More Than Meets the Eye: The Similarities Between Coronavirus Disease 2019 and Smoking

To The Editor: Research shows that cigarette smoking upregulates angiotensin-converting enzyme 2,the receptor by which severe acute respiratory syndrome coronavirus 2(SARS-CoV-2) gains entry to the host resulting in coronavirus disease2019 (COVID-19), in the lungs and, therefore, potentially leads to increased morbidity.1 However, the virus and smoking share far more similarities than meet the eye(Table).As part of a tobacco treatment campaign implemented at the beginning of the pandemic at McDonald Army Health Center, we performed a literature search and found thatSARS-CoV-2 and smoking both contribute to myocarditis, thrombosis, immune impairment, and increased inflammation.

Evaluation of the effect of COVID-19 disease on ventricular density using computer tomography

Aim: Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2) is a novel coronavirus identified at the end of 2019. Radiological examinations, especially thorax Computed Tomography (CT), play an important role in the fight against this infectious disease. In this study, we aimed to analyze the effect of COVID-19 disease on the cardiac ventricles by measuring density on CT. Materials and Methods: Patients who underwent thorax CT with a pre-diagnosis of COVID-19 and whose Polymerase Chain Reaction (PCR) test was positive, and patients who underwent CT for any reason were included in the study. Among 270 patients included in the study, 147 were men, 123 were women, and the mean age was 45.5 (29.2-62) years. The patients with a positive PCR test were divided into three groups. The control group and the three groups were compared with each other in terms of age, gender, CTR, right and left ventricular density. Results: In both studies, a significant difference was found between the groups in terms of age (p 0.005). There was no significant difference between Group 1 and Group 3 in terms of age, right and left ventricular density, and CTR (p 0.005). Discussion: In patients with COVID-19, cardiovascular comorbidities are common. Therefore, early diagnosis will boost the effectiveness of treatment. Considering the severity of the disease and the primary focus on managing infection and respiratory failure, not all patients have complete cardiac data and imaging results are not available. Ventricular density and CTR measurements on CT did not yield significant results in COVID-19 patients. However, we think that more patients and appropriate imaging will yield important results, as previous studies have shown the impact of COVID-19 disease on the cardiovascular system.

Suspected COVID-19-Induced Myopericarditis.

Background: The incidence of myocarditis in patients with coronavirus disease 2019 (COVID-19) remains unknown; however, increasing evidence links COVID-19 to cardiovascular complications such as arrhythmias, heart failure, cardiogenic shock, fulminant myocarditis, and cardiac death. We present a case of suspected COVID-19-induced myopericarditis and discuss the diagnostic implications, pathophysiology, and management. Case Report: A 72-year-old female was admitted to the hospital with acute on chronic respiratory failure in the setting of COVID-19. The next day, she developed pressure-like retrosternal chest pain. Laboratory findings revealed elevated cardiac enzymes and inflammatory markers consistent with myocardial injury. Electrocardiogram revealed diffuse ST segment elevations without reciprocal changes, concerning for myopericarditis. Transthoracic echocardiography showed new findings of severely reduced left ventricular (LV) systolic function, with an estimated ejection fraction (EF) of 20%. Her hospital course was further complicated by cardiogenic shock that required treatment in the intensive care unit with vasopressors and inotropes. During the next few days, she had almost full recovery of her LV function, with EF improving to 50%. However, her clinical status deteriorated, likely the result of a bowel obstruction. She was transitioned to comfort care at the request of her family, and she died shortly after. Conclusion: This case highlights diagnostic and therapeutic challenges that physicians may encounter when managing acute cardiac injury in the setting of COVID-19. The multiple mechanisms of COVID-19-related myocardial injury may influence the approach to diagnosis and treatment.

Sports Activity and Arrhythmic Risk in Cardiomyopathies and Channelopathies: A Critical Review of European Guidelines on Sports Cardiology in Patients with Cardiovascular Diseases.

The prediction and prevention of sudden cardiac death is the philosopher's stone of clinical cardiac electrophysiology. Sports can act as triggers of fatal arrhythmias and therefore it is essential to promptly frame the athlete at risk and to carefully evaluate the suitability for both competitive and recreational sports activity. A history of syncope or palpitations, the presence of premature ventricular complexes or more complex arrhythmias, a reduced left ventricular systolic function, or the presence of known or familiar heart disease should prompt a thorough evaluation with second level examinations. In this regard, cardiac magnetic resonance and electrophysiological study play important roles in the diagnostic work-up. The role of genetics is increasing both in cardiomyopathies and in channelopathies, and a careful evaluation must be focused on genotype positive/phenotype negative subjects. In addition to being a trigger for fatal arrhythmias in certain cardiomyopathies, sports also play a role in the progression of the disease itself, especially in the case arrhythmogenic right ventricular cardiomyopathy. In this paper, we review the latest European guidelines on sport cardiology in patients with cardiovascular diseases, focusing on arrhythmic risk stratification and the management of cardiomyopathies and channelopathies.

COVID-19 pandemia and inherited cardiomyopathies and channelopathies: a short term and long term perspective.

Inherited heart disease represent a very heterogenous group of cardiac disorders, characterized by inherited, acquired, and often rare disorders affecting the heart muscle (cardiomyopathies) or the cardiac electrical system (ion channel disease). They are often familial diseases, and are among the leading cause of juvenile sudden death and heart failure. The aim of this paper is to give a perspective on how to run a clinical service during an epidemic or pandemic emergency and to describe the potential COVID-19 associated risks for patients affected by inherited heart diseases.

Description and Proposed Management of the Acute COVID-19 Cardiovascular Syndrome.

Coronavirus disease 2019 (COVID-19) is a rapidly expanding global pandemic caused by severe acute respiratory syndrome coronavirus 2, resulting in significant morbidity and mortality. A substantial minority of patients hospitalized develop an acute COVID-19 cardiovascular syndrome, which can manifest with a variety of clinical presentations but often presents as an acute cardiac injury with cardiomyopathy, ventricular arrhythmias, and hemodynamic instability in the absence of obstructive coronary artery disease. The cause of this injury is uncertain but is suspected to be related to myocarditis, microvascular injury, systemic cytokine-mediated injury, or stress-related cardiomyopathy. Although histologically unproven, severe acute respiratory syndrome coronavirus 2 has the potential to directly replicate within cardiomyocytes and pericytes, leading to viral myocarditis. Systemically elevated cytokines are also known to be cardiotoxic and have the potential to result in profound myocardial injury. Prior experience with severe acute respiratory syndrome coronavirus 1 has helped expedite the evaluation of several promising therapies, including antiviral agents, interleukin-6 inhibitors, and convalescent serum. Management of acute COVID-19 cardiovascular syndrome should involve a multidisciplinary team including intensive care specialists, infectious disease specialists, and cardiologists. Priorities for managing acute COVID-19 cardiovascular syndrome include balancing the goals of minimizing healthcare staff exposure for testing that will not change clinical management with early recognition of the syndrome at a time point at which intervention may be most effective. This article aims to review the best available data on acute COVID-19 cardiovascular syndrome epidemiology, pathogenesis, diagnosis, and treatment. From these data, we propose a surveillance, diagnostic, and management strategy that balances potential patient risks and healthcare staff exposure with improvement in meaningful clinical outcomes.