Narrator: Coming up on Mayo Clinic Q&A, most people who get
COVID-19 recover fully within a few weeks, but some continue to
experience symptoms after that initial recovery. These people
are described as long haulers, or having long COVID, and among
the issues are problems with the heart and lungs.
Dr. Leslie Cooper: This is a virus that affects the lining of
the blood vessels. When they are infected they become
dysfunctional, and blood clots inside the blood vessels can
form, and that affects the heart as well as the lungs. Not only
can you have the common heart attack, or blood clots in the
veins, or the lungs, but also less common diseases like
myocarditis or pericarditis occur at a higher rate in
patients who have had COVID-19, both the younger as well as the
older patients.
Dr. Halena Gazelka: Welcome, everyone to Mayo Clinic Q&A. I'm
your host, Dr. Halena Gazelka. A recent study found that people
with COVID-19 are at an increased risk of heart disease
even a year after their infection. The study looked at
the health records of more than 150,000 U.S. veterans. It found
that people with prior COVID infections were 60% more likely
to develop cardiac issues. Joining us to discuss COVID
related cardiac disease is Dr. Leslie Cooper. Dr. Cooper is the
chair of cardiology at Mayo Clinic in Florida. Welcome back.
Leslie.
Dr. Leslie Cooper: Great to be with you today.
Dr. Halena Gazelka: Well, this is a fascinating study because
we're starting to hear so much more about long COVID and the
complications of COVID long-term. What did you think of
this study?
Dr. Leslie Cooper: Well, thank you so much for asking. This
was a really timely study. As you point out, we have seen
reports for about a year that six months or longer after acute
COVID, people have symptoms like chest pain or shortness of
breath. And we've been trying to figure out what is causing this.
Could it be damage to the lungs? Could it be damage to the heart,
or maybe the syndrome of deconditioning that comes after
a significant hospitalization. But this study, which was done
in 153,000 veterans, all of whom had COVID-19 and were followed
for about a year to look for cardiac symptoms, really set the
standard for the best quality data that gives us the highest
level of detail and in the largest population.
Dr. Halena Gazelka: Are you seeing this in your clinic as
well?
Dr. Leslie Cooper: Indeed, I am. This is just what I'm seeing in
clinic, many patients who are both the healthy younger
athletes, as well as the older patients who had pre-existing
cardiac disease, will come into the clinic with shortness of
breath or chest pain more than three months after COVID-19. And
at that point we start a search to figure out what could be
causing their symptoms.
Dr. Halena Gazelka: Leslie, what kind of cardiac disease comes
from COVID, or happens after COVID?
Dr. Leslie Cooper: Well, it turns out, I mean, there's a
large spectrum of disease. Not only can you have the common
heart attack, or blood clots in the veins or the lungs, but also
less common diseases like myocarditis or pericarditis
occur at a higher rate in patients who have had COVID-19,
both the younger as well as the older patients compared to
patients who are contemporary competitors or historical
competitors.
Dr. Halena Gazelka: I had mentioned a bit earlier about
long COVID or long hauler syndrome as it's been called.
Are these cardiac complications part of that or are they a
different sort of issue?
Dr. Leslie Cooper: Great question. And so, usually they
are. So, when you think about long COVID there's brain fog,
there's all kinds of neurologic symptoms that occur more than
three to six months after the initial illness. In addition,
there can be other effects in the kidneys or other organs. But
for the heart and lungs together, shortness of breath or
chest pain is not uncommon, occurring in 20 to 50% of people
six months after a hospitalization for COVID.
Dr. Halena Gazelka: I think one of the questions that naturally
comes to people's mind is does it matter how severe your case
of COVID was whether you develop cardiac complications? In other
words, if someone is more ill and they're hospitalized are
they more likely to have long-term cardiac disease than
someone who had a very mild case?
Dr. Leslie Cooper: Again, a great question, and it turns out
the answer is yes. This study by the VA investigators included
out of their 153,000 veterans, 131,000 who were not
hospitalized. They were not that sick. In addition, there
were smaller groups who were hospitalized and about 5,000 who
were in the intensive care unit. It turns out that in all of
those groups there was still a significant risk, excess risk
for most cardiac complications, but the risks were highest in
those people who were hospitalized or in the ICU for
COVID-19.
Dr. Halena Gazelka: And are there any other demographics
that seemed to make a difference? Like male versus
female, different medical comorbidities, etc.?
Dr. Leslie Cooper: Good question. So, it turns out these
authors had such a large population they could do
detailed subgroup analysis. And the subgroup analysis looked at
women versus men, as well as obese versus non-obese, and all
different age groups. And it turns out that there was a
significant increase in a broad spectrum of cardiac events in
men as well as women, older as well as younger individuals, as
well as people of different weights and different health
status.
Dr. Halena Gazelka: How interesting. So, it really
didn't make a difference?
Dr. Leslie Cooper: Yeah. So, each group in the subgroup
analysis for most of those endpoints which were heart
attack, stroke, myocarditis, for example, were significant in all
the subgroup analyses. There were a few where the number of
individuals, for example women versus men, may have been too
small to show a difference because they were looking at
about 10 different cardiac complications. And they were
doing it in a subgroup of maybe 12 or 14 subgroups. Which is
when you break that down the individual buckets, or numbers
of patients within each tiny subgroup, might be too small to
show a difference. But generally, the pattern to
remember is that almost all of the complications from a cardiac
standpoint were significantly elevated following COVID, a year
after symptom diagnosis in women, and men, and all the age
groups.
Dr. Halena Gazelka: Interesting. What is the actual impact on the
heart? Or what actually happens to the heart from COVID?
Dr. Leslie Cooper: Yeah, well there are two broad things that
happen in a severe COVID infection. One is you get
inflammation. So, because your body is responding to the virus
and the damage from the virus, your immune system secretes all
of these pro-inflammatory proteins called cytokines and
interleukins, which rev up your immune system to try and clear
the virus. As part of that, that immune reaction can cause damage
that can actually kill cardiac myocytes unintentionally. And
the other thing is clotting. This is a virus that affects the
lining of the blood vessels, the endothelial cells, and in that
when they are infected they become dysfunctional, and blood
clots inside the blood vessels can form next to those
endothelial cells, and that affects the heart as well as the
lungs. We know this from autopsy studies when people do histology
after someone dies or has a biopsy of the lung, we can see
that the tiny blood vessels often have clots.
Dr. Halena Gazelka: Is this damage irreversible when it
happens?
Dr. Leslie Cooper: I wouldn't say it's irreversible, but I
think it may take a very long time for remodeling. So, in
patients, for example, who have a decrease in the heart pump
function or cardiomyopathy, which is significantly increased
following COVID, it may take months, or even a year or two
for that heart to recover.
Dr. Halena Gazelka: And Leslie, do you treat these patients any
differently than people who would have similar cardiac
diseases that were not caused by COVID? Or is it similar?
Dr. Leslie Cooper: Well, that is an area of intense research
right now. If you have heart failure, for example, the
cardiomyopathy I mentioned, we would give you guideline
directed treatment, which affects people who either had
other causes, more common causes, like heart attacks, for
example, we would treat the same way as people who have COVID-19
cardiomyopathy. However, we think that because there are
specific mechanisms that in the future we will be treating more
specifically for perhaps anti-inflammatory therapies if
inflammation is an ongoing cause of the symptoms. Multiple
research studies are ongoing in this area.
Dr. Halena Gazelka: Interesting. Thank you so much. Any last
words to share with our listeners today, Leslie?
Dr. Leslie Cooper: I would say it's still very important to
protect yourself from COVID as the new variants come out.
Follow public health guidelines regarding either social
distancing, masking, frequent washing of hands, for example.
Keep up-to-date, for those guidelines are changing, and you
want to stay current.
Dr. Halena Gazelka: I have one last question about this study,
Leslie. Were the individuals in the study who developed COVID
and then heart disease vaccinated, or not vaccinated,
or both? And did it make a difference?
Dr. Leslie Cooper: The answer is both, and they controlled for
that, and they did not make a difference.
Dr. Halena Gazelka: Interesting. It's just the development of
COVID itself then?
Dr. Leslie Cooper: In general, although there is a very small
population of individuals who received vaccination, mainly men
between the ages of 12 and 39, who can have cardiac
side-effects. The rate of those side-effects is actually much
lower than the rate of cardiac complications if you got the
virus itself. So, the vaccine is safer than the virus, even in
young males.
Dr. Halena Gazelka: Oh, good to know. Thank you very much for
being here today, Leslie. This is really interesting.
Dr. Leslie Cooper: It's so good to be with you. Thank you so
much.
Dr. Halena Gazelka: Our thanks to Dr. Leslie Cooper, chair of
cardiology at Mayo Clinic in Florida, for coming here today
to discuss long COVID and its effects on the heart with us. I
hope that you learned something. I know that I did. We wish each
of you a wonderful day.
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