COVID-19 continues to dominate the news. As I write this blog the United States is reporting 793,919 confirmed cases and 42,474 deaths – the numbers change daily. Lots of data is emerging from China, Italy, and the hardest hit places in the United States such as New York City. While this is a respiratory virus, the cardiac complications are significant. Last week I hosted a webinar with the FH Foundation on COVID-19 and its cardiac complications. I provided information on cardiac complications in general and on FH in particular. This blog reviews our current understanding of the many ways COVID-19 can impact the heart, specific concerns for people living with familial hypercholesterolemia (FH) and what you can do to protect yourself.
Our goal is not to scare anyone during this particularly challenging time. As serious as this virus is, it's important to remember that most people will recover from a COVID-19 infection. Our aim at the FH Foundation is to support and empower individuals to make the most informed medical choices.
Infection with COVID-19 has been associated with multiple cardiac complications including: heart attack, myocarditis (inflammation of the heart muscle), arrhythmias (heart rhythm disturbances) and blood clots. Let’s take these in turn:
Heart Attacks and COVID-19
COVID-19 can also cause severe systemic inflammation. For people with underlying plaques within their heart arteries this can cause “unstable plaques,” which are prone to rupture. When this happens, a clot can form at the site of rupture leading to complete blockage of the artery. If not reversed quickly, the heart muscle served by that artery will die.
Myocarditis and COVID-19
As noted above, COVID-19 can cause widespread systemic inflammation and the release of many inflammatory proteins or cytokines including Interleukin 1 (IL1), Interleukin 6 (IL6), and tumor necrosis factor (TNF). This is also known as a “cytokine storm” which can lead to weakening of the heart muscle.
Arrhythmias and COVID-19
COVID-19 can cause many metabolic and electrolyte abnormalities which can also predispose someone to cardiac arrhythmias.
In addition, not surprisingly, widespread systemic inflammation is also capable of triggering arrhythmias.
Finally, some of the medications that are being used experimentally to try to treat COVID-19 are capable of causing arrhythmias including: lopinavir/ritonavir (drugs commonly used to treat Human Immunodeficiency Virus (HIV)) and chloroquine (used to treat malaria).
Blood Clots and COVID-19
To date, there have been multiple reports of abnormalities in blood clotting (coagulation parameters) seen in persons infected with COVID-19.
Some people infected with COVID-19 develop disseminated intravascular coagulation (DIC) in response to widespread inflammation. In DIC blood clots form inside multiple blood vessels. These clots use up all the blood’s clotting factors and ultimately lead to severe bleeding.
Am I at increased risk for cardiac complications of COVID-19 if I have FH?
If you have FH and already have heart disease or other risk factors such as high blood pressure or diabetes, you are likely at increased risk for complications if you contract COVID-19.
Can people with FH learn anything from other bacterial/viral pulmonary infections?
They also point out that the Atherosclerosis Risk in Communities (ARIC) study found a link between cytomegalovirus antibodies (a herpes virus) and atherosclerosis in persons with elevated lipoprotein(a) or Lp(a). Persons with FH tend to have higher Lp(a). Again, it is unknown if there will be similar findings following COVID-19 infection in people with FH and elevated Lp(a).
How can people with FH protect themselves from COVID-19?
There is little doubt that avoidance of infection is very important. Frequent hand washing and following social distancing guidelines are of the utmost importance.
If I think I have COVID-19, and need to go to the hospital, what should I bring with me?
We have posted a letter on our website that you can bring with you should you need to go to the hospital due to a COVID-19 infection. This letter discusses the potential increased cardiac risk that persons with FH, even those who haven’t ever suffered a cardiac event, might be under. The letter includes a sheet you can fill out that includes your past medical history, your health care providers’ names, and the medications you are taking. Additionally, we have posted another letter by Sotirios Tsimikas, MD of the University of California, San Diego that discusses issues surrounding having a high Lp(a) and developing a COVID-19 infection. If this is your situation, you could bring both letters.
We at the FH Foundation hope that you will stay healthy through this pandemic but want you to be prepared should you contract COVID-19. Please feel free to reach out to us with any questions or concerns through the comments below or by emailing email@example.com.
Driggin E. Cardiovascular Considerations for Patients, Health Care Workers, and Health Systems During the Coronavirus Disease 2019 (COVID-19) Pandemic, Journal of the American College of Cardiology (2020), doi: https://doi.org/10.1016/j.jacc.2020.03.031
Vuorio, A., Watts, G.F. and Kovanen, P.T. (2020), Familial hypercholesterolemia and COVID‐19: triggering of increased sustained cardiovascular risk. J Intern Med. Accepted Author Manuscript. doi:10.1111/joim.13070 Epub ahead of print