A heart attack? No, it was the corona virus

Mar 28, 2020 1:05 AM ET

The 64-year-old patient came to a Brooklyn hospital with symptoms similar to those in patients with a severe heart attack.

An electrocardiogram showed a threatening heart rhythm. The patient had high blood levels of a protein called troponin, a sign of damage to the heart muscle. Doctors hurried to open the patient’s blocked arteries – but found that no arteries were blocked.

The patient had no heart attack. The culprit was the corona virus.

The Brooklyn patient recovered after 12 days in the hospital and is now at home. However, there have been reports of similar patients in the US and abroad, and the cases have raised troubling questions for doctors.

What should doctors do nowadays when they see patients with obvious heart attacks? Should they rule out coronavirus infection first – or is it a waste of valuable time for the majority of patients who actually have a heart attack?

Should every coronavirus patient be tested for high levels of troponin in the blood to determine if the virus has attacked the heart?

“I don’t know what the correct answer is,” said Dr. Nir Uriel, cardiologist at Columbia University and Weill Cornell Medicine in New York.

The Brooklyn patient had myocarditis, an inflammation of the heart seen in patients with other viral infections. like MERS – also caused by a corona virus – and swine flu H1N1.

However, the new corona virus called SARS-CoV-2 mainly infects the lungs and causes pneumonia in severe cases. Many cardiologists believed that it caused respiratory diseases and thought the coronavirus was outside their specialty.

“We thought of lungs, lungs, lungs – with us in a supporting role,” said Dr. John Rumsfeld, Chief Science and Quality Officer at the American College of Cardiology. “Then we suddenly heard of possible direct effects on the heart.”

There was a report of heart problems in coronavirus patients in Wuhan, China published in JAMA Cardiology on Friday.

Dr. Zhibing Lu’s study at Wuhan University’s Zhongnan Hospital found that 20 percent of patients hospitalized with Covid-19, the coronavirus disease, showed signs of heart damage.

Many were not known to have an underlying heart disease. But they often had abnormal electrocardiograms, like the patient in Brooklyn, in addition to elevated troponin levels, which sometimes rose to levels seen in heart attack patients.

The risk of death in these patients was more than four times higher than in patients without cardiac complications.

The magazine also published a report from doctors in Italy that described a previously healthy 53-year-old woman who developed myocarditis.

Like the patient in Brooklyn, her electrocardiogram was abnormal and she had high levels of troponin in the blood. Because of the Corona virus outbreak in Italy, doctors thought to test it and found that it was infected.

Dr. Enrico Ammirati, a myocarditis expert at Niguarda Hospital in Milan, who consulted on the case, said the patient’s heart problems were probably due to her body’s immune response to the virus.

But so much is unknown about this new pathogen, and it is not yet clear what could cause heart damage after an infection.

“Myocarditis is likely to be caused either by the virus itself or by the body’s immune and inflammatory response to the virus,” said Dr. Scott Solomon, cardiologist at Harvard Medical School.

Infected patients who have myocarditis don’t necessarily have more viruses in their bodies than those who don’t develop the disease, he said.

It is possible – but not yet proven – that myocarditis is due to an immune system that gets out of control while trying to turn back the coronavirus and pumps out so many chemicals called cytokines that cause inflammation, the lungs and heart alike damage.

The disease, known as the cytokine storm, is more serious in the elderly and in people with chronic underlying conditions, said Dr. Solomon. It is the main reason for the serious complications of the respiratory tract, which can lead to death in patients with the coronavirus.

Cytokines also promote blood clotting and affect the body’s anticoagulant system, said Dr. Peter Libby, cardiologist at Harvard Medical School. Blood clots in coronary arteries can block blood flow and cause heart attacks.

Another option, said Dr. Libby, is that some coronavirus patients develop heart problems as a result of infections in their lungs.

“The lungs don’t work, so there isn’t enough oxygen,” he said. “This increases the risk of arrhythmias.”

At the same time, the fever caused by the virus increases the body’s metabolism and blood production in the heart. The result is that the patient’s heart is struggling with an increased need for oxygen, but with a reduced supply, an imbalance that can lead to heart damage.

However, doctors cannot rule out that the coronavirus directly damages the heart, several experts said.

In Seattle, a patient recently infected with the virus died of a so-called heart block: the electrical signals that emanate from the top of the organ and determine the normal heart rhythm did not reach the bottom of the heart.

In this case, the heart goes into an emergency mode with a so-called escape rhythm, which makes it beat very slowly. The man had an underlying lung disease that worsened his prognosis.

Dr. April S. Stempien-Otero, a cardiologist at the University of Washington, hopes that an autopsy will show whether the virus has attacked the man’s heart.

“We thought it was a heart block for the elderly,” she said. “Then Covid suddenly raises his head.”

From now on she said: “We have to think, maybe that’s the way it is.”

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