How COVID-19 Affects the Heart: What to Know If You Have an Increased Risk of Heart Disease from an Inflammatory or Rheumatic Condition

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Like most coronaviruses, COVID-19 is a disease of the respiratory system. Most patients infected with the coronavirus are asymptomatic or develop mild to moderate symptoms and recover in a week or two. The most common symptoms of COVID-19 include shortness of breath, low-grade fever, and a cough.

But as researchers and health care providers are still learning, COVID-19 is also a cardiac condition. “Although the effects on the respiratory system are the most obvious, there is good evidence that the virus affects the cardiovascular system as well,” says Sarah Samaan, MD, a cardiologist at Baylor Scott & White The Heart Hospital in Plano, Texas and author of Best Practices for a Healthy Heart.

The cardiac-COVID connection became apparent in the early days of the pandemic. In March, researchers in China documented heart damage in nearly 20 percent of patients (out of 416) hospitalized for COVID-19. In another Chinese study published in April, 16 of 36 patients admitted to the intensive care unit (ICU) had arrhythmias, a problem with the rate or rhythm of your heartbeat.

In addition to irregular heartbeats, an article in the journal Nature Medicine published in July identified a host of other potential heart-related problems from COVID-19 infection:

• Inflammation of the heart muscle (myocarditis)
• Reduced blood flow to the heart
• Sudden cardiac death

The virus does damage, in part, by triggering an overactive immune response that sets up “hyperinflammation.” When this inflammation affects the lining of the blood vessels, COVID-19 can raise the risk for blood clots that can affect the lungs, heart, and other vital organs. It’s important to note that the body’s reaction to the coronavirus is similar to when you get the flu or other viral infections, but in some cases, it’s a lot stronger.

This is especially sobering news for people with underlying heart disease, who may not be able to survive the additional stress that COVID-19 puts on the heart, and potentially for those who are already at higher risk of developing it.

Inflammatory Conditions and Heart Disease Risk

People with diseases that share common underpinnings with heart disease involving inflammation have an increased risk of heart disease. These include:

• Inflammatory arthritis like rheumatoid arthritis (RA), psoriatic arthritis (PsA), gout, or ankylosing spondylitis. Research shows that just having RA means your heart attack risk is as much as 68 percent higher than it is for someone without RA; your risk of stroke might be up to 40 percent higher. The risk of heart disease may be nearly doubled in people with PsA.
• Lupus can cause inflammation of the myocardium (myocarditis), the muscle tissue of the heart. The disease is so associated with cardiovascular issues that heart disease, not lupus itself, is the number one cause of death in people with lupus.
• Psoriasis, which has been found to increase the risk of major cardiac events, including heart attack (by 21 percent) and stroke (by 54 percent).

Other underlying conditions linked to a higher risk of heart disease include:

• Crohn’s disease can cause iron deficiency anemia that can lead to heart problems, such as a fast or irregular heartbeat. Over time, an enlarged heart or heart failure may develop.
• Diabetes can damage blood vessels and the nerves that control your heart. People with diabetes are also likely to have other conditions, such as high blood pressure, that raise the risk for heart disease.

While having cardiovascular disease doesn’t make people more likely to get the coronavirus, it is potentially more likely to worsen the course of the disease.

Data released in June by the U.S. Centers for Disease Control and Prevention (CDC) shows COVID-19 patients with underlying conditions, such as cardiovascular disease, are six times more likely to be hospitalized and 12 times more likely to die than patients without any chronic health problems. About one in three people with COVID-19 has cardiovascular disease, making it the most common underlying health condition.

How COVID-19 Damages the Heart

There are several ways COVID-19 may impact the heart, and the blood vessels seem to be an especially hard-hit target.

“COVID seems to really be a disease of the vasculature, where it’s affecting the blood vessels in many parts of the body, whether it’s the skin — hence, ‘COVID toes,’ an itchy, red-purple rash on the toes of people with the disease — brain, lung, or heart,” explains cardiologist Jennifer Haythe, MD, Assistant Professor of Medicine in the Division of Cardiology at the Center for Advanced Cardiac Care at Columbia University Medical Center in New York City.

The virus seems to attack the endothelium, a single layer of cells that lines the inside of blood vessels throughout the body. These cells play many important roles. They release substances that prevent clotting, control blood pressure, and protect the body from invading pathogens. While the endothelium normally helps maintain health, when it goes into overdrive, it can seriously worsen matters. According to a recent article, the inflammation caused by COVID-19 may activate platelets and trigger uncontrolled clotting throughout the body, which blocks blood supply to vital organs.

As a result, COVID-19 is most prone to negatively affect people who already have underlying vascular problems — for instance, people with diabetes, people who are obese, and people who have hypertension (high blood pressure). These comorbid conditions tend to be common in people who have inflammatory arthritis and rheumatic conditions.

“When vascular systems are already abnormal, it may be that it’s easier for the virus to affect those systems,” says Dr. Haythe, who works in the ICU with critically ill COVID-19 patients. CDC data on hospitalized patients in 14 U.S. states found that about one-third had chronic lung disease, nearly as many had diabetes, and fully half had pre-existing high blood pressure.

The consequences of this are being seen in multiple organ systems, whether it’s the lungs or the heart, in the form of small or even large blood clots that can potentially travel to the brain and lead to stroke or to the heart attack, she says.

A study in the journal Thrombosis Research found that nearly 40 percent of COVID-19 patients in the ICU had abnormal blood clotting and one-third already had blood clots.

Other heart complications of COVID-19 include:

Myocarditis

This inflammation of the cells of the heart appears to result from the direct infection of the virus attacking the heart, or possibly as a consequence of the inflammation triggered by the body’s overly aggressive immune response to mediating damage caused by COVID-19. Myocarditis can impair the heart’s ability to pump blood and send electrical signals, leading to chest pain and irregular heartbeats, some of which can be lethal.

Heart failure

Inflammation of the lining of the blood vessels from COVID-19 infection can be fatal in and of itself, but it can also cause less oxygen to reach the bloodstream. The extra strain this puts on the heart muscle to pump blood through the body can contribute to heart failure, which occurs when the heart muscle doesn’t pump blood as well as it should, says Dr. Samaan. In people with pre-existing heart disease, the heart can fail from overwork, or insufficient oxygen can cause cell tissue and tissue damage in the heart and other organs.

Cytokine storm

Most serious of all outcomes is the possibility of the immune system — via chemical signaling molecules called cytokines that help fight the virus — launching an attack that’s so beyond what’s needed that it destroys healthy tissue. Known as a cytokine storm, this response causes inflammation that overwhelms the body and damages organs like the heart so severely that it’s difficult for someone to survive.

Strain on the cardiovascular system

In the short term, even in cases where COVID-19 doesn’t directly injure the heart, it can put tremendous strain on the cardiovascular system — lowering blood oxygen levels and causing the heart to work harder to try and pump oxygenated blood through the body. For someone with pre-existing cardiovascular disease, who is already at especially high risk of complications of COVID-19, this is a serious concern, says Dr. Samaan. “Even if the virus doesn’t attack the heart, the stress and strain of such a severe illness may overtax an already weakened heart, leading to heart failure and serious heart rhythm disturbances.”

Heart Problems Linger After Recovering from COVID-19

Research that points to the heart damage wrought by COVID-19 continues to mount. One particularly alarming study published in July in JAMA Cardiology showed signs of ongoing heart involvement in patients who’d recovered from COVID-19 — even weeks or months after feeling better.

In the study, researchers examined the cardiac MRIs of 100 relatively young, healthy people (average age 49) who had recovered (mostly at home) from mild to moderate cases of COVID-19. More than two months later, 78 percent of recovered patients had lingering heart abnormalities, while 60 percent had ongoing myocarditis. Seventy-six people had evidence of the blood enzyme troponin, a biomarker that signals cardiac injury typically found after a heart attack.

The concern is that even with a mild case of COVID-19, there’s a possibility that there could be lasting inflammation and damage to your heart.

In another study published in JAMA Cardiology, an analysis of autopsies done on 39 older adults with COVID-19, found that these patients experienced unrecognized cardiac injury. It identified infections in the hearts of patients who hadn’t been diagnosed with cardiovascular issues while they were ill.

What Doctors Still Don’t Know About COVID-19 and the Heart

As worrisome as all this seems, experts aren’t exactly sure how to interpret findings like these or their long-term consequences.

“There are a couple of interesting studies, but we don’t know quite what they mean,” says Laurie Jacobs, MD, Chairperson of the Department of Internal Medicine at Hackensack University Medical Center in Hackensack, New Jersey, and Hackensack Meridian School of Medicine. “We don’t know if this is just that COVID-19 takes a long time to resolve and that there’s extra inflammation that’s asymptomatic and it goes away. Or does this affect a certain percentage of people and will it persist and maybe cause scarring and lead to chronic heart problems? We haven’t done longitudinal studies on these people, so we just don’t know.”

Making matters more confusing, a new literature review of 227 autopsies found that myocarditis is rare, occurring in less than 2 percent of cases. “A lot of us are left thinking that this might not be as prevalent as is thought or that maybe it goes away,” says Dr. Jacobs, who set up one of the first dedicated programs to provide medical assistance to recovering COVID-19 patients.

“The effects of COVID-19 on the heart are only beginning to be understood,” Dr. Samaan agrees. “The majority of people will survive COVID-19, but we are starting to see people coming in with chronic shortness of breath and fatigue months after they have cleared the virus,” she says. “We simply don’t know whether they will fully recover. Many may be left with lingering effects of the virus, especially those who suffer serious respiratory illness.”

How to Protect Your Heart

These concerns underscore the importance of preventing people — especially those at greater risk of developing more severe COVID-19 disease — from contracting or re-contracting (a phenomenon that’s reportedly increasing) the coronavirus.

Some steps to take include:

Avoid getting the virus

Vaccines are starting to roll out, but that doesn’t mean we can start taking fewer precautions. It’s still critical to follow the “3 Ws”:

• Wear a mask
• Watch your distance
• Wash your hands

“I’m shocked by the number of my heart patients who still believe that the risk [of contracting the virus] is ‘overblown,’” says Dr. Samaan. “The people who most need to be careful are sometimes those who are tempting fate, at a potentially terrible cost.”

Keep taking your heart medication

There was some early speculation that drugs commonly prescribed for people with high blood pressure or heart failure, such as ACE inhibitors (angiotensin converting enzyme inhibitors) and ARBs (angiotensin receptor blockers), could make people more susceptible to severe COVID-19. The theory was that the coronavirus could be binding to certain receptors in the lower respiratory tract, a common place for the virus to spread, and that these drugs may increase the number of these receptors.

At the time, experts stressed that there was no clinical data showing that the drugs had any effect — good or bad — on COVID-19 in people with or without heart disease, and they recommended continuing to take these medications, which have clear and well-established benefits.

What’s more, there is now newer research that shows the drugs aren’t harmful. In a study presented at a medical conference in September, researchers reported that suspending ACE inhibitors and ARBs for 30 days in patients hospitalized with COVID-19 did not impact the number of days alive and out of the hospital, which was the primary outcome researchers used to determine the drug’s safety.

The principal researcher, Renato Lopes, MD, PhD, of Duke Clinical Research Institute in Durham, North Carolina, concluded: “Because these data indicate that there is no clinical benefit from routinely interrupting these medications in hospitalized patients with mild to moderate COVID-19, they should generally be continued for those with an indication.”

Keep taking your medication for inflammatory and rheumatic conditions

If you have inflammatory arthritis or related conditions, it’s important to stay on your disease-modifying medications, which lower inflammation and keep disease activity in check. This, in turn, may help reduce your risk of underlying cardiovascular disease. It may also prevent disease flares that can increase pain and fatigue, which could prevent you from staying physically active — another way to reduce your heart disease risk.

The general consensus is that patients should not stop taking these medications unless you actually contract COVID-19, and even then you should talk to your health care provider before making any change in your treatment plan.

Get the flu vaccine

If you haven’t already gotten vaccinated, it’s not too late — the peak spread of the flu virus occurs in January and February, and people can continue to get sick into mid-May.

It’s especially important for people with underlying conditions like heart disease (as well as inflammatory and autoimmune conditions) to get a flu shot. They are at higher risk for developing serious complications from the flu (like the coronavirus, the flu virus can cause a lot of inflammation that can lead to blockages that can trigger a heart attack or stroke).

If you take immunosuppressant medication (such as disease-modifying antirheumatic drugs or biologics), have heart disease, or are 65 years or older, the nasal spray flu vaccine (FluMist) — which contains a live virus — isn’t recommended. According to the CDC, flu shots have a long, established safety record in people with heart disease. You can read more here about getting the flu vaccine when you have inflammatory arthritis.

Adopt or maintain healthy lifestyle habits

“A healthy lifestyle, including maintaining a healthy body weight, is particularly important in the age of COVID, since obesity is a major risk factor for complications of the disease,” says Dr. Samaan. Controlling diabetes is also important, since diabetes itself is another risk factor for COVID-19.

Be alert for red-flag heart symptoms

“Anyone who has underlying illnesses should pay close attention to their cardiac symptoms — fatigue, chest pain, or shortness of breath — and bring them to the attention of their doctor,” says Dr. Haythe. These same symptoms can also be symptoms of COVID-19 and need to be checked out, cardiologist Erin Michos, MD, associate professor of medicine at Johns Hopkins School of Medicine in Baltimore, explained on John Hopkins Health.

If you think you’re having a heart attack or some other cardiovascular issue, seek prompt medical care. Untreated heart attacks can lead to long-term complications, so don’t ride it out at home because you’re worried about COVID. Hospitals are set up to protect people from contracting the disease.

Research shows that people are afraid to go to the hospital during the pandemic and, as a result, are needlessly dying — often at home. One study published in September found that there were over 2,000 excess deaths — an average of 17 a day for four months — due to heart disease and stroke during the peak of the pandemic.

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