There are 2 aspects of Covid 19 infection that have important interactions with heart disease. These interactions have unexpected implication for the treatment of people with infection and provide clues for developing therapies. The first discussion relates to the increased susceptibility of people with heart disease to the Covid 19 infection. The second issue relates to the impact of infection on subsequent heart disease and cardiac events.
posted on MARCH 16, 2020
People with heart disease are more susceptible to complications and death related to Covid 19.
It’s clear that the coronavirus Covid 19 affects older people disproportionately.
Don’t forget however that middle-aged people are more numerous and although the mortality rates in those over 70 in particular are quite high many middle aged people develop infection, symptoms, and complications. Problems in patients with Covid 19 are also related to coexistent chronic diseases which increase with age. Since this is a respiratory infection it would seem likely that pre-existing lung disease would be a powerful predictor of bad outcome. In reality heart disease is a much more powerful predictor.
Effect of coexisting conditions on mortality rates in Covid 19 infections.
Heart disease is prevalence is high and not just in the elderly.
Unfortunately, the risk conferred by heart disease is not restricted to elderly. 40% of Americans in the age group of 40 to 60 have heart disease, and a much higher proportion and those over 60 have heart disease.
What we can learn from the strong relationship of heart disease to Covid 19.
There is much speculation regarding the cause of the relationship with Covid 19 infection. Through the study of other coronavirus infections it’s been determined that these viruses enter cells through a receptor on cell membranes called ACE2 receptor.
The ACE2 receptor is part of the Renin Angiotensin System (RAS system). The RAS system is highly activated in cardiovascular disease. RAS activation leads to inflammation and artery constriction and is an underlying cause of hypertension, and heart disease.
In China, 85% of Covid 19 patients have received Traditional Chinese Medicine with supplements designed to increase the amount of ACE2 enzyme in hopes that it will occupy and block access of the Covid 19 virus to the receptor. This may impair the viruses ability to gain entry into the cell.
Another way to increase ACE2 enzyme are dietary flavonoids. This is another strong argument for a vegetable rich diet. Antibodies to the ACE2 receptor are also being developed.
Whether therapies directed to increasing ACE2 enzyme helps anything is purely speculative and unproven, but this relationship may help explain the relationship of heart disease to Covid 19 complications. This is an example of how powerful and important it is to fully understand this infection. Treatment and prevention of this infection will be dependent on continued investment and advances in virology.
Infection can increase subsequent risk of heart complications.
Infections also have impact on heart disease. Influenza, bacterial pneumonia, chronic viral and stealth infections such as chronic Lyme disease, are all associated with subsequent increased risk of cardiovascular events.
N Engl J Med 2019; 380:171-176
Risk of MI is elevated and remains elevated for prolonged periods following infection.
This observation speaks to the importance of inflammation as an underlying cause of heart disease and shows the limitation of focusing solely on cholesterol.
N Engl J Med 2019; 380:171-176
Just as influenza and other infections increase subsequent risk of cardiovascular events, we may also suspect that Covid 19 infection will have a similar effect.
Be proactive about increased cardiovascular risk.
The increased risk of cardiovascular complications after acute infections and with chronic infections is under-appreciated. Attention to the effects of inflammation on heart disease is important and identifying and reducing inflammation is an important goal. Patients with recent or chronic infection require special attention, measurement of inflammation markers, and will benefit from a Functional Medicine approach to this issue.
Lessons for the future.
These lessons from the interaction of Covid 19 in people with heart disease and the possible relationship of Covid 19 to subsequent heart disease are enlightening and important. Our health care providers on the front lines are working tirelessly for us in this pandemic as are many brilliant people working to better understand this virus and bring forward new treatments.
J Thomas Svinarich MD FACC FHRS