Cardiovascular Risks

Covid is One of These

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Sara Galeazzi

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Sara Galeazzi, 24 years old. Graduate in Chemistry, Materials and Biotechnology. Graduated in Techniques Cardiocirculatory Pathophysiology and Cardiovascular Perfusion at the University of Pavia and specialized in basic and advanced Echocardiography at the University of Padua.She worked as a perfusionist technician in cardiac surgery, cardiology, pulmonology, intensive care, vascular diagnostics, and thoracic surgery at the Polyclinic San Matteo in Pavia and as a cardiac sonographer in molecular cardiology at the ICS Maugeri of Pavia.She works as a hostess, beauty consultant, fragrance consultant and promoter for luxury brands.She's interested in the world of gym and fitness.

Cardiovascular diseases are largely preventable, as they recognize, alongside non-modifiable risk factors (age, gender and family history), also modifiable factors, linked to behaviors and lifestyles. Covid-19 can be added to cardiovascular risk factors. People who have tested positive for Covid-19 are at higher risk of incurring cardiovascular disease and related clinical events, such as heart failure, myocardial infarction, stroke and arrhythmia.

Cardiovascular diseases are a group of diseases which include ischemic heart diseases, such as acute myocardial infarction and angina pectoris, and cerebrovascular diseases, such as ischemic and haemorrhagic stroke. They represent the main causes of morbidity and disability in Italy and are still the main cause of death, being responsible for 34.8% of all deaths.

Cardiovascular risk quantifies the probability of suffering a disease affecting the heart or blood vessels based on the presence or absence of certain predisposing factors.

Cardiovascular diseases are preventable, as they recognize, alongside non-modifiable risk factors (age, gender, and family history), also modifiable factors, linked to behaviors and lifestyles which often, in turn, cause diabetes, obesity, hypercholesterolemia and arterial hypertension. The risk factors that can be corrected through correct lifestyles and/or pharmacological treatments include: insulin resistance and/or hyperinsulinemia, diabetes mellitus, smoking habit, arterial hypertension, overweight, obesity (abdominal circumference > 102 cm in men or > 88 cm in women), early menopause, LDL hypercholesterolaemia, HDL hypocholesterolaemia, hypertriglyceridemia, MPV > 12 fl, hyperhomocysteinemia, inadequate diet, alcohol and drug abuse, stress,sedentary lifestyle, elevated fibrinogen and C-reactive protein values in blood, antithrombin III deficiency.

High cholesterol is undoubtedly an important cardiovascular risk factor as it is deposited on the walls of the arteries, damages the vessels, and favors the formation of plaques, therefore a narrowing of the arteries; however, its relevance in the genesis of these diseases, which we have seen to have a multifactorial aetiology, has long been overestimated. Today, the choice of whether or not to undertake a specific pharmacological therapy is not dictated by exceeding a particular total cholesterol value, but by the overall assessment of the subject's cardiovascular risk. In this regard, the Higher Institute of Health (ISS) drew up the so-called cardiovascular risk map a few years ago. It is a series of tables and suggestions that allow calculating the risk of suffering a major cardiovascular event (heart attack and stroke), fatal or non-fatal, in the following 10 years, in subjects who have not already suffered one. To estimate the absolute cardiovascular risk in the following 10 years it is necessary to take into consideration six factors, namely gender, age, LDL cholesterol, the presence or absence of diabetes, hypertension, and smoking habits.The identification of people at medium and high cardiovascular risk makes it possible to undertake actions capable of positively modifying the lifestyle and other unfavorable but modifiable elements; gender and age for obvious reasons cannot be corrected. In this regard, it is still widely believed today that cardiovascular diseases mainly concern men, and the vast majority of women have a very low perception of the dangers caused by these pathologies. In fact, cardiovascular diseases occur in women with a delay of at least 10 years compared to men. Until menopause women are helped by hormonal protection; subsequently, women are affected even more than men by cardiovascular events, which are often more serious, even if they manifest themselves with a less evident clinical picture: many times, in fact, the pain is absent, is localized elsewhere or is confused with that resulting from other diseases. For this reason, women generally go to the hospital later than men.

The risk that each person has of developing cardiovascular disease depends on the extent of the risk factors; the risk is continuous and increases with age; therefore, there is no level at which the risk is zero. However, cardiovascular risk can be reduced or maintained at a favorable level by lowering the level of modifiable factors through a healthy lifestyle, quitting smoking, following a healthy diet, training, and controlling weight.

Covid-19 can be added to all these cardiovascular risk factors. But how does our heart react to the Covid pandemic? Can the virus cause cardiovascular problems in the long term?

SARS-CoV 2 (Covid-19) infection in its most severe forms is primarily known as an acute respiratory syndrome secondary to direct and indirect lung damage. However, the picture is much more complex if we ascribe this pathology to a systemic and contemporary involvement of several systems. Even the cardiovascular system can be seriously damaged by Covid-19, but its involvement is not yet clear and understood.

It has been widely documented, especially in the review of the last two years of the pandemic, that Covid can create cardiovascular risks. However, we must remember that it can create them especially in patients with a high comorbidity or already carriers of heart or vascular diseases. During the Covid infection, the heart can be damaged especially in symptomatic patients where we know that the infection causes a problem of super inflammation and a hyperimmune response: these conditions lead to a series of consequences that can involve the heart, because they involve damage to the coronary microcirculation or may be a consequence of the fact that patients who frequently arrive at the hospital have pneumonia which reduces the oxygenation capacity of the blood: thus causing indirect damage to the heart. Additionally, the virus can enter heart cells and can lead to generalized vasculitis.

In addition to the increasing prevalence of CVD risk factors, people who test positive for Covid-19 are at higher risk of cardiovascular disease and related clinical events, such as heart failure, myocardial infarction, stroke, and arrhythmias. People who test positive for Covid-19 more frequently develop symptoms associated with cardiovascular disease (CVD) and, because of the pandemic situation, an increase in the burden of these pathologies is expected in the medium and long term, accompanied by the urgency to respond to a crescendo of unmet needs in the management of these patients. Among those who develop Covid-19, individuals with cardiovascular disease are up to 3.9 times more likely to experience severe symptoms and a probability to die up to 2.7 times more likely than Covid patients with no underlying cardiovascular conditions.

More specifically, acute myocardial injury is identified as a sudden rise in troponin levels. The mortality rate for Covid-19 is higher in patients with more pre-existing comorbidities such as diabetes mellitus, renal insufficiency, arterial hypertension or a history of coronary artery disease, who therefore initially have less ability to implement compensatory mechanisms; but it is also higher in those patients with higher levels of interleukin 6, C-reactive protein, procalcitonin, ferritin and D-dimer which therefore indicate a more violent inflammatory process. Similarly, elevated troponin levels have been shown to be associated with a worse prognosis. The presence of anacute heart damage during SARS CoV2 infection therefore seems to lead to a worse prognosis and a greater risk of death.At this point it is important to understand whether the myocardial damage is due to a direct action of the virus towards the heart and towards the vessels or is a secondary phenomenon to a serious general impairment of all the systems due to an advanced septic state of the patient. Although it initially appeared that the virus could cause severe direct myocardial injury, it is now known that a multifactorial etiology of myocardial injury is more likely. To date, the most accredited hypothesis is that myocardial damage is secondary to multiple events that are generated during the massive inflammatory response during Covid-19 such as the cytokine storm, endothelial and microvascular damage, and an increase in metabolic demands in patients with a reduced coronary reserve.

Unlike other pneumonias, however, the SARS-Cov2 syndrome has a marked prothrombotic tendency, with a greater risk of venous thrombosis and pulmonary thromboembolism which can affect the prognosis. The origin of myocardial damage is plausibly multifactorial and therefore secondary to hypoxia due to increased oxygen demand, massive release of inflammatory mediators, and procoagulation. This can lead to arrhythmic forms, myocarditis, pericarditis, and everything related to thromboembolic disease such as myocardial infarction and stress cardiomyopathy.  All of this in the Covid era reached a peak never reached in the past.

With Long Covid we mean what happens at least 12 weeks after the acute illness. On the one hand there are the consequences of the alterations experienced in the acute phase such as inflammatory phenomena, linked to coagulation alterations or to the possibility of ischemic events. These patients may have long-term chest pain, many report it but it is not always a match with the tests that are done. And then palpitations and heartbeat alterations, for which the psychological component also affects, the tiredness, general weakening, fatigue and breathing difficulties. Then there are some healed who present specific phenomena of cardiac involvement. These are pericarditis or myocarditis developed in the acute phase which can continue over time or arise later. What was seen with the first data collected is a reduced distensibility of the heart which becomes less "elastic" and this, in the future, could predispose to heart failure more easily. In addition, there are arrhythmias, linked to inflammatory or fibrotic outcomes, which can appear after some time. As for the long term, from the data collected so far, there does not seem to be an increase in mortality from cardiac causes. In the long run, however, cardiac magnetic resonance often shows alterations, such as the presence of fibrous scars on the heart that reflect what happened in the first phase.

Based on what we know now, in the long run surely something on the heart remains. We still don't know how serious these effects are, if they will resolve over time, if they will leave indelible scars or if they will lead to a worsening of health conditions.

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