Coronary Microvascular Dysfunction is Common in Patients Hospitalized with COVID-19 Infection

Alterations in genes associated with cytosolic RNA sensing in whole blood are associated with coronary microvascular disease in SLE

Systemic lupus erythematosus (SLE) patients are 90% women and over three times more likely to die of cardiovascular disease than women in the general population. Chest pain with no obstructive cardiac disease is associated with coronary microvascular disease (CMD), where narrowing of the small blood vessels can lead to ischemia, and frequently reported by SLE patients. Using whole blood RNA samples, we asked whether gene signatures discriminate SLE patients with coronary microvascular dysfunction (CMD) on cardiac MRI (n=4) from those without (n=7) and whether any signaling pathway is linked to the underlying pathobiology of SLE CMD. RNA-seq analysis revealed 143 differentially expressed (DE) genes between the SLE and healthy control (HC) groups, with virus defense and interferon (IFN) signaling being the key pathways identified as enriched in SLE as expected. We next conducted a comparative analysis of genes differentially expressed in SLE-CMD and SLE-non-CMD relative to HC samples. Our analysis highlighted differences in IFN signaling, RNA sensing and ADP-ribosylation pathways between SLE-CMD and SLE-non-CMD. This is the first study to investigate possible gene signatures associating with CMD in SLE, and our data strongly suggests that distinct molecular mechanisms underly vascular changes in CMD and non-CMD involvement in SLE.

Increased Angio-Derived Index of Microcirculatory Resistance Within a Timeframe of 30-60 days After COVID-19 Infection

BACKGROUND AND OBJECTIVES

Chest pain is a relatively long-term symptom that commonly occurs in patients who have contracted COVID-19. The reasons for these symptoms remain unclear, with coronary microvascular dysfunction (CMD) emerging as a potential factor. This study aimed to assess the presence of CMD in these patients by measuring the angio-derived index of microcirculatory resistance (AMR).

METHODS

In this cross-sectional case-control study, patients who had chest pain and a history of COVID-19 infection within the preceding 30 to 60 days were included. The control subjects were patients without COVID-19. Demographic, clinical, and echocardiographic data were recorded. Angiographic images were collected for AMR analysis through an angioplus quantitative flow ratio measurement system. Propensity score matching (PSM) was performed to match the two groups. Multivariate logistic regression was used to examine the association between COVID-19 incidence and the increase in AMR (AMR > 285 mmHg*s/m) after correction for other confounders.

RESULTS

After PSM, there were 58 patients in each group (the mean age was 66.3 ± 9.04 years, and 55.2% were men). The average time between the onset of COVID-19 infection and patient presentation at the hospital for coronary angiography was 41 ± 9.5 days. Moreover, there was no significant difference in the quantitative flow ratio between the two groups. Patients with COVID-19 had a greater mean AMR (295 vs. 266, p = 0.002). Multivariate logistic regression analysis revealed that COVID-19 (OR = 3.32, 95% CI = 1.50-7.60, p = 0.004) was significantly associated with an increase in AMR.

CONCLUSIONS

Long-term COVID-19 patients who experience chest pain without evidence of myocardial ischemia exhibit an increase in AMR, and CMD may be one of the reasons for this increase. COVID-19 is an independent risk factor for an increase in AMR.

Interatrial Block and Electrocardiographic Markers of Repolarization in Patients Hospitalized with COVID-19: Classical and Bayesian Analysis

Objective

Coronavirus disease-2019 (COVID-19) is associated with atrial fibrillation (AF) and ventricular arrhythmias. Several electrophysiological abnormalities on surface electrocardiography (ECG) are associated with AF and ventricular arrhythmias, either as markers of abnormal interatrial conduction or abnormal repolarization. The present study sought to understand whether such ECG markers are more common in patients hospitalized with COVID-19 infection during the pandemic.

Methods

A total of 87 COVID-19 patients formed the study group, whereas 64 patients who were hospitalized for any reason other than COVID-19 infection served as controls. The frequency of partial and advanced interatrial block (IAB), QT and corrected QT (QTc) durations, QT dispersion (QTd), and T peak-to-end duration (Tpe) were measured from ECGs at admission.

Results

Both partial and advanced IAB were more common in patients with COVID-19, although statistical significance was only observed for advanced IAB (11.5% in COVID-19 patients vs. 0.0% in controls, p=0.005). There were no differences between the groups for QTc, QTd or Tpe. On Bayesian analyses, there was strong evidence favoring an association between COVID-19 and advanced IAB (BF10:16), whereas there was no evidence for an association for partial IAB, QTc, QTd, or Tpe (BF10<1 for all).

Conclusions

Patients hospitalized with COVID-19 were more likely to have advanced IAB, which may explain why AF is more frequent in these patients.

Sequence and directivity in cardiac muscle injury of COVID-19 patients: an observational study

Objective

To compare cardiac function indicators between mild and moderate to severe COVID-19 patients and to try to identify the sequence and directivity in cardiac muscle injury of COVID-19 patients.

Methods

From December 2022 to January 2023, all patients with laboratory-confirmed SARS-CoV-2 infection in Shanghai General Hospital Jiading Branch were enrolled. The clinical classification was stratified into mild, moderate, or severe groups. We collected the clinical and laboratory information, transthoracic echocardiographic and speckle-tracking echocardiographic parameters of patients and compared the differences among different groups.

Results

The values of echocardiographic parameters in mild group were lower than that in moderate or severe group (P < 0.05) except LVEF. The values of LVEF of mild and moderate group were higher than severe group (P < 0.05). There were no significant differences between moderate and severe group. Positive correlations were observed between left ventricular global longitudinal strain (LVGLS) and myoglobin (r = 0.72), E/e' and age (r = 0.79), E/e' and BNP (r = 0.67). The multivariate analysis shows that SpO2 (OR = 0.360, P = 0.02), LVGLS (OR = 3.196, P = 0.003) and E/e' (OR = 1.307, P = 0.036) were the independent risk factors for mild cases progressing to moderate or severe. According to the receiver operating characteristic (ROC) curves, when all the COVID-19 patients was taken as the sample size, the area under the curve (AUC) of the LVGLS was the highest (AUC = 0.861). The AUC of the LVGLS was higher than LVGCS (AUC = 0.565, P < 0.001).

Conclusion

When mild COVID-19 progresses to moderate or severe, both systolic and diastolic functions of the heart are impaired. LVGLS was the independent risk factor for mild cases progressing to moderate or severe cases. Longitudinal changes may manifest earlier than circumferential changes as myocardial disease progresses in COVID-19.

COVID-19 STEMI related to microthrombi may lead to coronary microvascular dysfunction

Coronavirus disease 2019 (COVID-19) increases the risk of ST-segment elevation myocardial infarction (STEMI), and is associated with a higher occurrence of nonobstructive coronary artery disease. We present a unique case of STEMI with concomitant COVID-19 infection in a young female found to have slow flow in multiple vessels on angiography, likely due to microvascular thrombi. Three months later, the patient developed coronary microvascular dysfunction (CMD), suggesting an evolution of microvascular thrombi and injury into subsequent CMD.

Circulating Biomarkers in Coronary Microvascular Dysfunction

Coronary microvascular dysfunction is an underdiagnosed pathologic process that is associated with adverse clinical outcomes. Biomarkers, molecules measurable in the blood, could inform the clinician by aiding in the diagnosis and management of coronary microvascular dysfunction. We present an updated review of circulating biomarkers in coronary microvascular dysfunction representing key pathologic processes, including inflammation, endothelial dysfunction, oxidative stress, coagulation, and other mechanisms.

Familial hypercholesterolemia: The nexus of endothelial dysfunction and lipoprotein metabolism in COVID-19

PURPOSE OF REVIEW

Patients with heterozygous familial hypercholesterolemia (HeFH) are at increased risk for COVID-19 cardiovascular complications in the acute phase of the infection. Elevated levels of LDL-C and often lipoprotein(a) are present from birth and lead to endothelial dysfunction, which is aggravated by a direct viral attack of the endothelial cells and their exposure to the toxic levels of circulating proinflammatory and prothrombotic mediators during the hyperinflammatory reaction typical of COVID-19.

RECENT FINDINGS

Evidence to date shows the benefit of lipid-lowering therapy in patients with COVID-19. In HeFH patients who are at much higher cardiovascular risk, the focus should, therefore, be on the effective lowering of LDL-C levels, the root cause of the greater cardiovascular vulnerability to COVID-19 infection in these patients. The ongoing use of statins and other lipid-lowering therapies should be encouraged during the ongoing COVID pandemic to mitigate the risk of cardiovascular complications from COVID-19, particularly in HeFH patients.

SUMMARY

Epidemiologic registry data show that the incidence of myocardial infarction is increased in SARS-CoV-2-infected HeFH patients. There is a need to study whether the risk for acute cardiovascular events is increased in the long-term and if there are changes in lipid metabolism after SARS-CoV infection(s) in patients with HeFH.

Multimodality Cardiac Imaging in COVID

Infection with SARS-CoV-2, the virus that causes COVID, is associated with numerous potential secondary complications. Global efforts have been dedicated to understanding the myriad potential cardiovascular sequelae which may occur during acute infection, convalescence, or recovery. Because patients often present with nonspecific symptoms and laboratory findings, cardiac imaging has emerged as an important tool for the discrimination of pulmonary and cardiovascular complications of this disease. The clinician investigating a potential COVID-related complication must account not only for the relative utility of various cardiac imaging modalities but also for the risk of infectious exposure to staff and other patients. Extraordinary clinical and scholarly efforts have brought the international medical community closer to a consensus on the appropriate indications for diagnostic cardiac imaging during this protracted pandemic. In this review, we summarize the existing literature and reference major societal guidelines to provide an overview of the indications and utility of echocardiography, nuclear imaging, cardiac computed tomography, and cardiac magnetic resonance imaging for the diagnosis of cardiovascular complications of COVID.

MICROCIRCULATORY ALTERATIONS IN STABLE CORONARY ARTERY DISEASE PATIENTS WITH CONCOMITANT COVID-19

OBJECTIVE

The aim: To evaluate the alterations in microcirculation of stable coronary artery disease (SCAD) patients with concomitant COVID-19.

PATIENTS AND METHODS

Materials and methods: The cross-sectional study analyzed the data from 80 patients, being subdivided as follows: group 1 (G1) - SCAD without COVID-19 (n=30); group 2 (G2) - SCAD with concomitant COVID-19 (n=25); group 3 (G3) - COVID-19 without SCAD (n=25). The control group included 30 relatively healthy volunteers. The state of microcirculation was assessed by nailfold videocapillaroscopy (NVC) and laser Doppler flowmetry (LDF).

RESULTS

Results: NVC data from G2 revealed the sings of capillary bed remodeling, along with the most pronounced decrease in capillary (arteriolar part of the loop) blood flow velocity (vs. G1 and G3). LDF data from G2 were evident for the alterations in both endothelium-dependent and -independent mechanisms of microvascular flow regulation. The 72 % of G2 constituted the cases of microcirculatory hemodynamic «congestion-stasis» (MHCS) type (characterized by the decreased laser Doppler perfusion index and reduced endothelium-dependent microvascular reactivity [MVR]), and the cases of mixed type with reduced MVR. The pooled hyporeactive profile (of both MHCS type and a mixed type with reduced MVR) demonstrated the higher frequency of G2 patients (40 %), as against 11 % in the pooled alternative hemodynamic group (p<0,001) (included 80 % of cases with preserved MVR).

CONCLUSION

Conclusions: G2 profile demonstrated the predomination of patients, possessing a MHCS type or a mixed type with reduced MVR. The pooled microcirculatory hyporeactive profile was presented with G2 cases to a greater extent, than in the pooled profile with predominantly preserved MVR.

Long-term assessment of systemic microcirculatory function and plasma cytokines after coronavirus disease 2019 (COVID-19)

Systemic microvascular dysfunction has been shown to be present in COVID-19, and serum cytokines are known to be involved in the regulation of vascular function. We sought to evaluate systemic microvascular endothelial function, with laser doppler perfusion monitoring (LDPM), and plasma levels of cytokines after acute COVID-19. Individuals admitted to a Cardiology hospital with acute COVID-19 and followed for 12-15 months after recovery underwent noninvasive evaluation of systemic endothelium-dependent microvascular reactivity by cutaneous LDPM with local thermal hyperemia (LTH). A multiplex biometric immunoassay panel was used to assess 48 serum cytokines and chemokines. Twenty patients and 14 control volunteers were enrolled. The areas under the curves of vasodilation induced by LTH were significantly increased after recovery (P=0.009) and were not different from values obtained in healthy volunteers (P = 0.85). The peak microvascular flow during LTH did also significantly increase (P = 0.02), and was not different form values obtained in healthy volunteers (P = 0.55). Several cytokines displayed significantly reduced serum concentrations after recovery from COVID-19. In conclusion, endothelium-dependent systemic microvascular reactivity improved after recovery from COVID-19 in patients with cardiovascular diseases, in parallel with a reduction in the levels of several serum cytokines and chemokines involved in the regulation of vascular function and inflammation.