© Pediatr Med Rodz 2019, 15 (4), p.

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DOI: 10.15557/PiMR.2020.0002

Received: 23.03.2020
Accepted: 25.03.2020
Robert Ryczek, Paweł Krzesiński Published: 31.03.2020

Cardiac patients and COVID-19: what the general practitioner should know
Pacjenci kardiologiczni a COVID-19 – co lekarz rodzinny wiedzieć powinien
Department of Cardiology and Internal Diseases, Military Institute of Medicine, Warsaw, Poland
Correspondence: Robert Ryczek, Department of Cardiology and Internal Diseases, Military Institute of Medicine, Szaserów 128, 04-141 Warsaw, Poland, tel.: +48 261 816 372, e-mail: rryczek@wim.mil.pl

The pandemic of COVID-19 (coronavirus disease 2019), a disease caused by the novel coronavirus SARS-CoV-2 (severe acute
Abstract respiratory syndrome coronavirus 2), presents medicine with previously unknown challenges. Primary healthcare facilities and
general practitioners face a number of problems related to the current epidemiological situation. The gravity of the situation
affects not only patients who are suspected of or diagnosed with COVID-19. New threats and organisational restrictions must
also be taken into consideration when providing medical care to other patients, especially those with chronic diseases, requiring
regular monitoring. Even though COVID-19 presents as a a mild respiratory disease in the majority of patients, it may pose
a serious risk to health and life in the elderly population and individuals with underlying health concerns. The presence of
previously diagnosed cardiovascular diseases is associated with an especially poor prognosis in patients with COVID-19.
The aims of the paper are to present the cardiovascular symptomatology of COVID-19 and the potential effect of SARS-CoV-2
infection on the laboratory cardiac markers, discuss the impact of cardiac disorders on the course of COVID-19, and summarise
the current expert statement on the controversies surrounding the treatment with angiotensin converting enzyme inhibitors
and angiotensin receptor blockers during the COVID-19 pandemic. In addition, attention is drawn to the fact that cardiac
patients can use telemedicine to get advice from specialists, so that continuity of care is ensured while adhering to the rules of
epidemiological safety.

Keywords: 2019-nCoV, cardiovascular system, COVID-19, SARS-CoV-2, telemedicine, hypertension

Pandemia COVID-19 (coronavirus disease 2019), choroby wywoływanej przez nowego koronawirusa SARS-CoV-2 (severe
Streszczenie acute respiratory syndrome coronavirus 2), stawia przed współczesną medycyną niespotykane dotychczas wyzwania. Placówki
podstawowej opieki zdrowotnej i lekarze rodzinni stykają się z szeregiem problemów spowodowanych obecną sytuacją
epidemiologiczną. Nie dotyczą one jedynie pacjentów z podejrzeniem bądź rozpoznaniem COVID-19. Również opieka nad
innymi osobami, zwłaszcza obarczonymi schorzeniami przewlekłymi, wymagającymi regularnej kontroli, musi obecnie
uwzględniać nowe zagrożenia i ograniczenia organizacyjne. Choć u większości zarażonych COVID-19 przebiega pod
postacią łagodnej infekcji dróg oddechowych, to dla osób starszych i obciążonych dodatkowymi schorzeniami choroba ta
może stanowić istotne zagrożenie dla zdrowia i życia. Obecność wcześniej rozpoznawanych chorób układu sercowo-
-naczyniowego wiąże się ze szczególnie złym rokowaniem u pacjentów z COVID-19. Celem pracy jest przedstawienie
symptomatologii COVID-19 ze strony układu sercowo-naczyniowego, potencjalnego wpływu infekcji wirusem SARS-CoV-2
na laboratoryjne markery sercowe, omówienie wpływu schorzeń kardiologicznych na przebieg tej choroby oraz przedstawienie
obecnego stanowiska ekspertów wobec kontrowersji dotyczących stosowania w okresie pandemii COVID-19 inhibitorów
konwertazy angiotensyny i blokerów receptora dla angiotensyny. Chcemy również zwrócić uwagę czytelników na możliwości
wykorzystania porad telemedycznych w celu zapewnienia ciągłości opieki nad chorym kardiologicznych z zachowaniem
bezpieczeństwa epidemiologicznego.

Słowa kluczowe: 2019-nCoV, układ sercowo-naczyniowy, COVID-19, SARS-CoV-2, telemedycyna, nadciśnienie tętnicze

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 Cardiac patients and COVID-19: what the general practitioner should know

INTRODUCTION also with the development of cardiovascular complica-

T
tions including exacerbation of symptoms of heart fail-
he confrontation of the contemporary global ure and arrhythmia, increased prevalence of myocardial
world with the pandemic caused by a novel coro- infarction, and elevated risk of sudden cardiac arrest (up
navirus (severe acute respiratory syndrome coro- to 3%)(6). The above data indicate that cardiac patients
navirus 2, SARS-CoV-2) has presented us with unprec- are at a particularly high risk of severe clinical course
edented challenges. The Chinese experience shows that of SARS-CoV-2 infection and death from the disorder.
epidemiological tools can be effective in combating the Based on the current state of knowledge there is no ef-
epidemic, but the rapidly growing number of infected fective causal treatment for COVID-19, and a vaccine
individuals in countries of the Old World increases the is a considerable time away from being ready for public
risk of every healthcare professional coming into contact use. Consequently, the only way to reduce spread of the
with the disease caused by the coronavirus SARS-CoV-2, disease is to adhere to the rigorous regime of safety pro-
called COVID-19 (coronavirus disease 2019). According cedures during the pandemic. Especially the elderly and
to the data of the European Centre for Disease Prevention patients with cardiovascular diseases should avoid leav-
and Control (ECDC), as of 31 March 2020 there were ing the house during this time, try to minimise contact
a total 777,798 confirmed cases of COVID-19 (European with people (social distancing), and stay away from pub-
Union: 386,282) including 37,272 deaths (European lic places and gatherings.
Union: 26,110)(1).
LABORATORY CARDIAC MARKERS
SYMPTOMATOLOGY OF COVID-19 AND COVID-19
AND SYMPTOMS INVOLVING
THE CARDIOVASCULAR SYSTEM Elevated troponin levels associated with COVID-19 may
be a marker of cardiovascular involvement and thus a risk
The clinical presentation of SARS-CoV-2 infection in- factor for more severe clinical course of the coronavirus
cludes elevated body temperature (≥37.3°C), found in infection. A meta-analysis of four observational studies
94% of hospitalised patients, as well as typical respirato- shows that an increase in the level of high-sensitivity tro-
ry symptoms: cough (79%) and expectoration of mucus ponin outside the normal range occurs in patients with
(23%)(2). However, patients may also seek medical atten- a more severe clinical course of COVID-19, who require
tion because of less specific symptoms, including those in- management in the intensive care unit, and is associat-
dicative of a cardiovascular disease, such as heart palpita- ed with a higher mortality. Consequently, rising troponin
tions or a feeling of heaviness in the chest(3). Nearly 12% levels determined during hospitalisation are a predictor of
of patients admitted to hospital with COVID-19 present- unsuccessful treatment outcome(7). An elevated D-dimer
ed with symptoms of myocardial damage (defined as an concentration is, next to old age, one of the strongest risk
increase in high-sensitivity troponins above the normal factors for unfavourable prognosis in patients hospitalised
limit, abnormalities in electrocardiogram or echocardiog- with COVID-19. D-dimer levels exceeding 1 µg/mL on
raphy)(4). Most of these patients required treatment in in- admission have been found to cause an up to 20-fold in-
tensive care units, and myocardial involvement was as- crease in the risk of death(6).
sociated with an increased risk of death(2). Post-mortem
findings also indicate myocardial damage secondary to ACEI/ARB AND THE RISK
SARS-CoV-2 infection(5). OF COVID-19 – CONTROVERSIES

EFFECTS OF EXISTING CARDIAC DISORDERS Angiotensin converting enzyme 2 (ACE2) is attached to

ON THE COURSE OF COVID-19 the cell membranes of a variety of cells including pulmo-
nary alveoli. The enzyme plays an important role in the
A number of studies have shown that in addition to acute functioning of the cardiovascular system, but also in the
cardiac damage due to the cardiotropic activity of the development of hypertension and diabetes. On the other
virus, another factor contributing to poorer prognosis hand, coronaviruses are known to use ACE2 as a recep-
in COVID-19 is the presence of previously diagnosed tor for infection (an observation made both during the
cardiovascular disorders. In patients hospitalised with 2002/2003 epidemic caused by SARS-CoV and the cur-
COVID-19, pre-existing coronary artery disease causes rent pandemic triggered by SARS-CoV-2). SARS-CoV-2
a 21-fold increase in the risk of death, while in patients develops primarily in alveolar endothelial cells, which
with arterial hypertension and diabetes the risk is in- explains the occurrence of respiratory symptoms in in-
creased 3-fold. The disorders have a significantly greater fected individuals. ACE2 secretion is greater in patients
prevalence in COVID-19 patients compared to the gen- with cardiovascular diseases compared to the healthy
eral population. Higher mortality rates in this group are population, which may be responsible for the more se-
associated not only with acute respiratory failure, but vere course of COVID-19 in this group. An increased
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PEDIATR MED RODZ Vol. 15 No. 4, p. c6–c9 DOI: 10.15557/PiMR.2020.0002
 Robert Ryczek, Paweł Krzesiński

secretion of ACE2 is also attributed to the blockade of discontinuation of ACEI/ARB. However, this therapeu-
the renin–angiotensin–aldosterone system (RAAS) via tic option is absolutely contraindicated in patients with
commonly used angiotensin converting enzyme inhib- left ventricular systolic dysfunction or symptoms of heart
itors (ACEI) and angiotensin receptor blockers (ARB)(8). failure. The coming weeks are expected to bring new ob-
Consequently, there are reasonable concerns about “sen- servations, opinions and conclusions regarding this con-
sitising” the pulmonary tissue to SARS-CoV-2 through troversial topic.
the use of these drugs, and hence their contributo-
ry effect on a more severe clinical disease presentation TELEMEDICINE DURING
of COVID-19 (3). These concerns are based in part on COVID-19 PANDEMIC
the observation that patients requiring intensive care
units stay tend to have a higher blood pressure com- It needs to be highlighted that cardiac patients require
pared to individuals receiving treatment in general hos- regular medical care provided not only by primary care
pital wards (2). However, there is no scientific evidence physicians, but also specialists. During the COVID-19
for a link between ACE2 activity and mortality associat- pandemic, patients should be protected from poten-
ed with COVID-19. The studies by Chinese authors cit- tial exposure to SARS-CoV-2 by avoiding visits to their
ed above(2,4,6) fail to specify how many patients with ar- healthcare facilities. However, in many cases treat-
terial hypertension were treated with RAAS blockers. ment can be continued based on telemedicine tools.
Therefore, no conclusive relationship can be estab- The National Health Fund allows this form of provid-
lished between the RAAS blockade and the outcomes of ing outpatient healthcare services to patients followed-
COVID-19 treatment. As a rule, drugs of this group are up in a given healthcare facility, in accordance with the
used primarily in the elderly population, having a great- established care plan and the patient’s clinical condition.
er number of comorbidities, i.e. a population normal- Experts of the Polish Cardiac Society strongly recom-
ly associated with a higher mortality rate. The results of mend the use of telemedicine during the period of the
experimental studies in animal models are ambiguous. COVID-19 pandemic. The experts’ statement is out-
It needs to be noted, though, that one of the studies suc- lined in the communication(13) available on the website
cessfully advanced the opposite thesis that the adminis- of the Section of Non-invasive Electrocardiology and
tration of ARB protects lungs against injury in mice(9). Telemedicine (https://senit.pl/node/184). The authors
Consequently, based on the current state of knowledge, it of the paper encourage readers to become familiar with
is not possible to establish any direct links between ACE2 the experts’ statement and guidelines for the implemen-
activity and the invasiveness of SARS-CoV-2 (10). On the tation of telemedicine services. In view of the current un-
other hand, there is a body of solid scientific evidence precedented challenges for the healthcare system, tele-
showing a beneficial effect of RAAS blockers on the out- medicine is expected to develop rapidly as a useful tool
comes of patients with heart failure, hypertension and re- for the implementation of new models of cardiac care.
cent myocardial infarction. Consequently, the European One such concept is currently being piloted within the
Society of Cardiology (11) and the European Society of framework of the AMULET study co-financed by the
Hypertension(12) clearly and firmly advise against the dis- National Centre for Research and Development under
continuation of drugs targeting the RAAS system in pa- the STRATEGMED programme by a consortium led by
tients at a risk of infection or infected with SARS-CoV-2. the Military Institute of Medicine in Warsaw(14).
If concerns are voiced by patients in the context of infor-
mation published in generally available resources or on CONCLUSIONS
the Internet, they should be promptly addressed. Patients
should be informed about well-documented benefits of The ongoing pandemic of coronavirus disease is a great
using these drugs in order to dispel any doubts there challenge for the contemporary world, fraught with un-
might be about their potentially harmful effects, which knowns because of the unknown nature of the novel
so far are only speculative in nature and require scien- virus. However, available studies of patient series pro-
tific validation. Patients should also be given clear infor- vide evidence that COVID-19 poses a particularly seri-
mation that the risk of disease complications is markedly ous threat to individuals with cardiac diseases. Patients
higher in the population of cardiac patients, and cardio- with cardiovascular disorders have a more severe clinical
vascular complications (such as exacerbation of symp- course of COVID-19 and higher mortality rates. These
toms of heart failure), are routinely treated with drugs unfavourable outcome statistics are attributable to di-
inhibiting RAAS activity. In cases involving increased rect damage to the heart caused by the virus, but most-
patient concerns about taking the drugs, a change in the ly they are due to the infection-induced exacerbation of
treatment regimen may be considered for the duration symptoms of chronic diseases. Reports on COVID-19
of the pandemic only in cases of arterial hypertension, are fresh, and relate primarily to the Chinese popula-
provided that the change in therapeutic modality offers tion. Unified data on the course of COVID-19 in the
c8 a chance to obtain adequate pressure control after the European population are yet to be revealed. Long-term

DOI: 10.15557/PiMR.2020.0002 PEDIATR MED RODZ Vol. 15 No. 4, p. c6–c9

 Cardiac patients and COVID-19: what the general practitioner should know

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