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David Pong, M.D.

By: David Pong, M.D. on February 12th, 2021

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Heart Health & COVID-19: A Few Thoughts

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It's February. It's Heart Month. And unfortunately, it's Heart Month in 2021, which makes it Heart Month in the COVID pandemic.

We've had a lot of questions about the impact of COVID-19 on heart disease and vice versa. And so I thought it would be a good time to share a little bit of information about that. I'd like to break this up into three segments.

The first is getting a sense of how underlying cardiovascular disease carries risk for more severe episodes of COVID-19. The impact of our underlying disease on our experience if we get COVID.

The second part would be to look at what happens when we get infected with COVID-19 and its impact on our hearts.

And then the third is something we might call post-acute COVID, which is some of the residual things that have happened in some of the people we've seen after they've had their acute episode of COVID. Watch the video below and read on for a full transcript. 

Recommended Reading: Researchers Investigate What COVID-19 Does to the Heart, Journal of the American Medical Association

Pre-Existing Cardiovascular Disease & COVID-19

So, first off, there's been a lot of different information and articles that have come out looking at the impact of preexisting cardiovascular disease on COVID-19 and the risk of having more severe episodes in people with underlying heart disease. And this turns out to be true both for folks with refined heart disease as well as folks with risk factors.

So we see it in folks with obesity, smoking, hypertension, diabetes, and certainly in people who have underlying either vascular disease, such as coronary artery disease, or underlying congestive heart failure, or valvular dysfunction. So all of these things lead to a higher risk for developing more severe COVID-19 outcomes, more hospitalizations, and unfortunately higher rates of dying.

One really important piece to take away is everything we do to lower our risk factors and the impact or the amount of cardiovascular disease, and risk factors we have present, leads to a lower risk for complications of COVID.

This has been a challenging time for a lot of us in terms of our exercise and dietary habits. There's kind of a standing joke that COVID-19 refers to the 19 pounds we've all gained as we've lost our ability to go to the gym and we've been forced to eat out of our refrigerators all day instead of being at work.

This is a really important time to try your best to find a way to move every day, to look for ways to increase the intensity of your exercise, and try to look at the diet, focusing on diets that have lean protein, plenty of produce, fats coming from plants and fish as your calories will allow, and trying to really limit the refined carbohydrates and the fats from animals.

So it is an important time to make changes as much as possible, despite recognizing how hard that is right now.

Another area like that is in smoking. And certainly this may be an opportunity for some people to quit smoking as well. And I really encourage that. If we can help in any way with any of these, please let us know. We're absolutely happy to try and do everything we can.

How COVID-19 Affects the Heart During Infection

Second part of this is to think about the impact of COVID-19 on us when we have, or at least on our hearts, when we get an acute infection. It turns out that the receptor that the virus uses to get into our cells is something called the ACE2 receptor.

And this receptor is expressed in very high amounts in our lung tissue, and in our respiratory tissue, and in our cardiovascular system. So the virus is directly coming into those tissues. And remember what viruses do is they inject their material into us.

Those cells that are infected become virus producing cells. And in doing so, it kills them. So we have a lot of damage going on, acute damage to different tissues in our respiratory tree and in our cardiovascular system. So that direct damage can be seen.

And it turns out it's not just COVID, there are a number of different viruses that can do this. In influenza, for example, certain types of functional studies of the heart will show evidence that the heart is inflamed during episodes of influenza.

Now, with influenza we rarely see any complications of that and it appears that most everybody returns to normal. With COVID that actually doesn't seem to be the case.

There have been studies showing perhaps as many as 60 or 70% of people with acute COVID will have active inflammatory processes going on in the heart. And we know from some of the anecdotal studies, or reports and some of the studies done that some people, even young, healthy people, will have conduction difficulties, they'll have sudden death.

They can have valvular changes or congestive heart failure as a result. So the damage done directly by the virus is problematic.

The virus also can set up an immune response. And so we see a lot of problems with overactive immune systems. You remember from early in the days of the pandemic they would talk about the cytokine storms.

And much of this dysregulation of the immune system can also have an impact, causing inflammation throughout our cardiovascular system. And again, that can lead to valve problems, it can lead to problems with the muscle of the heart itself, and problems with the plumbing that feeds the heart.

We also see an increase in clotting. We can get deep venous clots that can then eventually end up showering the lungs or causing strokes. We can have arterial clotting. So we can see trouble in the peripheral system. You've all heard of COVID toes.

You can also see small strokes. You can see large strokes. You can see difficulty feeding the heart, both through the named large vessels on the surface of the heart, but also the small vessels that are in the substance of the heart can get plugged. So problems from acute COVID are all over the place.

Another way that we see it is sometimes through the acute lung infections. The pneumonia changes the pressures involved where the heart pumps blood into the lungs. And we can see heart failure because of the increased pressure that the heart pumps against.

Heart Health Post-COVID Infection

We also can see post-acute COVID changes. After the acute phase of COVID, in the weeks after, we see people who sometimes will have difficulty returning to their regular exercise.

They'll be short of breath. They'll have difficulty with persistent fatigue or lightheadedness. And some of those people will be found to have conduction problems on an EKG, or structural problems on an echocardiogram.

We may be able to see that they have some new trouble with feeding the heart on something like a stress test. So we find it's very important as you go through COVID to do so ideally in partnership with your doc. And certainly if at any point you have an increase in shortness of breath, if you have chest pain, if you have lightheadedness, if you have any palpitations, there would be evaluation steps to do.

And as you come out, as you feel good afterwards, as your energy returns and you start to get back to exercise, we want to check in with you and make sure that you're not having any of those symptoms.

Again, pain, or palpitations, or lightheadedness, or difficulty as you try and increase your exercise. It's very important to take that gradually as you first get into your recovery.

And again, if you have any questions about that, we'd be very interested in trying to help you sort that out and make sure that you're in a safe position.


So again, three things to consider. One is that that, like so many things, the healthier you are going into COVID-19, the more likely it is that you will have a safer outcome. And that's very true in terms of cardiovascular disease. So anything you can do in terms of exercise, diet, smoking cessation, weight loss, control of the risk factors, blood pressure, obesity, diabetes, cholesterol. Any of those steps you're taking, any work you're doing in regard to those, should over time lower your risk in terms of both COVID, but also of course it's beneficial in terms of longevity and quality of life that you have a healthy heart.

Acute COVID generally, especially in younger people, the lighter your symptoms the less risk there is for lasting impact on heart function. But there are certainly exceptions. The more sick you are, if you end up in the hospital, if you end up in the ICU, much higher probability of having active heart difficulty from the virus and from the immune response after.

And especially following the post-acute COVID, and in the recovery, it's very important to monitor people after if they're having any symptoms at all, any difficulty with persistent shortness of breath, or pain, or palpitations.

So we ask you to pay attention to all of those. We're happy to try and work with you at any time.

And otherwise, again, this is scary stuff. None of us want to think about being at my age, in our 50s or 60s, and having strokes or heart attacks. And unfortunately, this respiratory virus seems to be able to increase that risk. I really ask you to pay attention to primary prevention, wash your hands, wear your masks. Really think about the people you're with and minimizing contact with people outside of the people you live with in your household.

Take steps to lower your risk for heart disease, separate from COVID, in terms of your exercise, diet, smoking at all. And if you happen to get COVID, please let us walk with you through that to try to help reduce the chances of having any of these terrible complications.

If you're able to get vaccinated, recognizing how frustrating that's been, I encourage vaccination as another step to lowering your risk.