• Pam King Sams

Penn Medicine cardiologist, Dr. Rhondalyn McLean, explains how COVID-19 can affect the heart.

Rhondalyn McLean of the Perelman School of Medicine spoke about how COVID-19 can affect the heart. “If the heart has already been weakened by a heart attack or other damage from long-standing high blood pressure, for instance, then the heart is less able to handle those stressors,” she said. “By that, I mean the stressors of infection and inflammation due to COVID-19. So you end up with a vicious cycle—the heart needing to work better, but unable to do so.”

What have we learned about COVID-19 and the heart?

The most important thing we’ve learned about COVID-19 and heart disease is that we have so much more to learn. This is a new disease and a new diagnosis, and it will take us a while to know what the long-term effects of the disease and of our treatments of it are going to be.

In general, we know that adults of any age with underlying medical conditions can be at increased risk for severe illness if they get COVID-19. Those include heart-related conditions like high blood pressure, diabetes, and stroke. It also includes things like an immunocompromised state. For me, as the head of the heart transplant program, I care for many people who have heart disease and who are immunocompromised. So that’s one part of it. If you have background cardiovascular disease, you’re twice as likely to develop severe illness if you get COVID-19.

What we also now know is that COVID-19 can lead to an exacerbation of already-existing heart disease. During illness, the heart beats stronger and faster in order to keep up with the demands of the body. As you can imagine, if the heart has already been weakened by a heart attack or other damage from long-standing high blood pressure, for instance, then the heart is less able to handle those stressors. By that, I mean the stressors of infection and inflammation due to COVID-19. So you end up with a vicious cycle — the heart needing to work better, but unable to do so.

The other thing that can happen is that the virus can cause direct damage to the heart. It does so by invading the heart muscle and leading to inflammation. And that condition is called myocarditis.

It’s not that uncommon to have mild forms of myocarditis with COVID-19. Studies have looked at heart MRIs of people who have COVID-19, and they reveal inflammation of the heart.

What worries me is that, although it’s rare, myocarditis can progress and become a big problem. When it does progress, it can lead to enlargement of the heart. The heart can become weak. And the heart can fail.

What are the symptoms of myocarditis?

People become short of breath. They become extremely fatigued. People can feel palpitations, like their heart is racing. The blood pressure can become low. One can get swelling in the legs and abdomen. Or develop a cough. The most common symptom, though, is shortness of breath. Patients will say things like, “I used to be able to walk up a flight of stairs, no problem. But now I have to stop and catch my breath.”

Who is more likely to experience these effects? Is age a factor?

It is true that the person who has an underlying condition or is over age 65 is much more likely to have severe COVID-19 and also to have COVID-19-related manifestations of heart disease. It’s also true that the more underlying conditions you have, the more likely you are to have severe COVID-19.

But what I think is important to say is that while children and young people tend to have milder forms of COVID-19, they do get infected. They can get sick. And they certainly can spread the virus to other people. We also know that they can develop myocarditis, just like adults do.

One of the other things to note is that people can get a milder form of COVID-19, but weeks later come in with a form of myocarditis. Though more likely to happen in older people, it occurs in both the young and the old.

I don’t want anyone to think this is just a disease of older people, or older people with preexisting conditions. People of all ages who are otherwise well can also become very sick.

What is the treatment for myocarditis?

We treat heart failure with our best medications — we have a host of different classes of medications from which to choose. They’re actually really good, and people do tend to get better. But sometimes people will require support with intravenous medications, machines or even heart transplant. So this is a serious thing.

I should also note that if you’ve had a history of myocarditis in the past, there’s an increased risk of recurrence. There are other viruses that can cause myocarditis, however COVID-19 is much more likely to do so than any of these other viruses.

Are there any indications that these cardiac effects will be long-term, perhaps even lifelong?

We don’t know yet. Time will be the only thing that will teach us that, and I don’t know how long that will take. It’s concerning, though, that there are people with mild cases of COVID-19 that seem to get better, and then three weeks later, the patient develops inflammation of the heart.

I think we eventually will know the long-term effects, because there are more than 25 million people thus far who have been infected in this country.

Another point is that every day, we learn something different. Every day, we learn something more. There are people who have terrible cardiovascular disease who only get mild forms of COVID-19. And there are others with terrible cases of COVID-19 illness that don’t have cardiovascular effects. What will be important is understanding what makes one patient’s situation differ from another’s.

One final point about the effects of COVID-19 on the heart: Many hospitals are filled with people who have COVID-19. So people who have heart disease are not coming in, either because they don’t have access or because they are afraid of getting COVID-19. People will go to the emergency room only after they have chest pains for five days, say, instead of right away. A lot of people are dying of heart attacks and other cardiovascular disease because they don’t come into the hospital in time. I’d like to say to them, “regardless of the reason for your hesitation, come in anyway.”


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