Covid-19 can cause entire spectrum of heart diseases, says cardiologist

COVID-19 is affecting the heart, as studies have shown, and patients with pre-existing heart conditions also have a higher incidence of severe disease, making it a double-edged sword, Sameer Gupta, an interventional cardiologist at the Metro Hospitals and Heart Institute in Delhi, says.

Recovered COVID-19 patients are coming back with stress cardiomyopathy--a temporary weakening of the heart muscle--and myocarditis (weakness of the heart muscle due to inflammation), Gupta says in this interview, explaining that this is an effect of the massive infection or inflammation, and not of the virus itself.

Gupta specialises in interventional cardiovascular and peripheral procedures. He completed his medicine residency at Penn State University, his fellowship at the University of South Florida, and interventional cardiology fellowship at the University of Chicago. Gupta has recovered from COVID-19 himself.

Edited excerpts:

As a cardiologist, what are you seeing today in terms of the symptoms or the progression of COVID-19?

COVID does affect the heart, and patients who have heart disease also have a higher incidence of bad problems with COVID. So, it is kind of a double-edged sword.

We have seen patients who have heart failure (which means the heart muscle is weak to begin with), blockages, and coronary artery disease have a higher incidence of bad prognosis (or death) with COVID. Also, some of the risk factors that cause these problems like diabetes and hypertension also increase the risk of bad problems with COVID.

On the other hand, COVID--in somebody who does not have heart disease--also causes the entire spectrum of heart disease. It increases the risk of arrhythmias (abnormal heart rhythms). We have seen that there is a higher incidence of [heart] muscle weakness, and heart attacks in patients with COVID.

What are the trends amongst the patients whom you have treated? Have they come back later with problems related to the heart?

I am an interventional cardiologist, so I am not treating COVID patients directly. But we do get consults. We see patients who have either contracted COVID in the past, or patients with heart disease who now have COVID and go to another facility. The prognosis has not been very good in some of these patients. I remember one patient distinctly. He had a massive heart attack. We treated him, and he went home. Then he developed COVID after a few weeks and had a bad prognosis, and he ultimately died.

So we have seen people come back with COVID. We have also seen patients who had COVID come in with other heart issues.

These are people who have recovered from COVID technically, but have subsequently shown heart issues. Is that correct?

Heart issues with COVID come in multiple flavours. We are seeing patients who recovered from COVID come back with heart failure, and then we see that they have cardiomyopathy (weakness in the heart muscle). There is some data to show that sometimes the weakness of the muscle is temporary (stress cardiomyopathy), and that it can be treated with medicines. We do not have long term studies yet, because the virus is only nine months old.

Are there any demographic similarities--in terms of age or gender--amongst COVID-19 patients who have shown some symptoms of heart conditions post their recovery?

No, that incidence right now is very small. So it is difficult to quantify and categorise. But on the other side, people who have heart issues like myocardial injury and heart failure when they are sick with COVID are typically older people. They are people who have risk factors like hypertension, diabetes or pre-existing heart disease, and develop complications of COVID in the heart. There is also myocarditis, which is weakness of the heart muscle due to inflammation.

The question that comes up is: Is the virus causing myocarditis and the heart muscle injury? Or is the inflammation and everything else going on in the body making the heart an innocent bystander? From the autopsy studies and data, we are finding that the heart is the innocent bystander. Our entire body lives in a sort of an equilibrium: Everything is codependent on each other. So, if there is a massive infection or a massive inflammation happening in the body, it does affect the heart also.

Is there anything to say that the heart is more affected than other organs?

The lungs, the heart and the coagulation system are primarily affected. In COVID patients, we see that the blood becomes thick because there are various changes in the coagulation pathway. And there is a higher incidence of blood clots, which then go into the lungs--and we have seen a lot of massive blood clots in the lungs, which are also a cause of death. These blood clots can happen in the brain, arms, legs… we have seen a lot of that.

If I already have a heart condition, how can I be more careful? You said that people who had come with a heart problem have developed COVID subsequently.

These people are definitely at a higher risk. I live in Delhi, and when I go out on the streets, I find that Delhi is back to about 75-80% of pre-COVID traffic. The streets are flooded. The good thing is everybody is at least wearing a mask. Even if it is on the chin, at least they are conscious enough to wear a mask.

I see that there is a lot of caution fatigue: People were very cautious to begin with in March, April and a little part of May. Now, as time has gone by, people are getting fatigued. I would like to remind everyone that even though we might be having 700-800 cases every day, you do not want to be one of those 700 cases. Please be vigilant. Do not go out for unnecessary get-togethers; do not go out and socialise just because you are bored. You cannot get into caution fatigue.

Also, take your medicines. In the initial part of the lockdown, we saw some patients were unable to procure medicines for whatever reason. Medicines were available, but they got lazy. They came back with complications--not of COVID, but with heart-related complications because they were non-compliant with medicines. So, please take your medicines. If you have diabetes, please take your diabetes medicine. I cannot stress this enough.

And it is very important to continue exercising, continue working out, because that is also something we have seen--that people are not working out. Please work out and keep yourself healthy. That is very important.

And that keeps the heart alive and kicking as well, in a metaphorical way.

Yes, definitely. Cardiovascular fitness is extremely important. Another thing I would like to point out is that in the initial part of the lockdown--and in some cases, even today--people are hesitant to come to the hospital. I got a few calls from patients in an emergency, hesitant to come to the hospital due to fear of exposure.

Heart disease has not gone away. Even today, heart disease is among the top killers in India. Yes, you can have [or could be at risk for] COVID, but you can still have a heart attack. So please do not ignore your symptoms.

You mentioned 700 cases. And you were also one of those 700 and suffered from it. So tell us about your experience.

It was a Monday, and I got up in the morning with a tickle in my throat, and a little bit of body pain. COVID is not the first thing [you think about], though I was exposed to a few COVID patients working in the hospital. People come in with a heart attack, and you do not know who has COVID and who does not.

So I got up with a tickle, I worked the entire day. I started having some back pain. And I thought it was due to the way I slept, or the lead I wear during procedures [to block radiation]. I was very tired, I went to sleep. I woke up at 4 in the morning with a fever, and realised that it has to be COVID. I woke my wife up and told her that I have a fever, and immediately did physical distancing. A few hours later, even she had a fever. So, we both got COVID.

Thankfully, it was the mild version. I just had a fever for a few days. My oxygen saturation and everything else was good. And I recovered, I did my entire two-three weeks of quarantine. I went beyond the recommendations because if I want to go back into the workforce, I have to ensure that I am not even 1% infected. So I did two negative tests, just for my own satisfaction, and then I went back into the workforce. I even donated my plasma.

I am assuming that both you and your spouse recovered at the same time?

Yes. It was variable. I had symptoms for about three to four days. She had very mild fever for five or six days. But we finished our quarantine together. We observed physical distancing.

You do not realise it, but a lot of healthcare professionals across the world are observing physical distancing from their loved ones. When cases started increasing, and I knew that there were people coming into the hospital with other symptoms who later on were found to have COVID, I started physically distancing from my parents who live in the same building as I do. I started interacting with them only wearing a mask. That is the reality of what many healthcare professionals across the world are doing. I know people who have not hugged their child for six months. They just cannot take the risk.

As you look ahead and given your own personal experience and the experience you have gained from treating patients, what is your sense? Do we have some control of this disease? Would you say, for instance, that our sense of control is at least 50% now, as opposed to nothing maybe four or five months ago? Or do you feel we still have a long way to go?

This is a great question. And the thing about this disease is that every day, we are learning something. It is also very interesting how the entire medical community and some of the best scientific minds in the world have come together to try and help and contribute to [fighting] the pandemic. If you go back and see the timeline, it was initially said that the masks were not helpful. Then they came and said masks are helpful. They said hydroxychloroquine is good, then they said it is not good. Now, new treatments are coming up.

We know a lot more than we did six months ago, and six months later, we will know a lot more than we know today. So, I think it is very gratifying as a scientist, cardiologist and a doctor to see how everybody has come together.

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