Cardiovascular Manifestations of SARS CoV-2: A Review
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic is a public health emergency of global concern. Besides the profound severe pulmonary damage, SARS-CoV-2 infection also causes a series of cardiovascular abnormalities, including myocardial injury, myocarditis and pericarditis, arrhythmia and cardiac arrest, cardiomyopathy, heart failure, cardiogenic shock, and coagulation abnormalities. COVID-19 patients with preexisting cardiovascular diseases are often at a much higher risk of increased morbidity and mortality. Number of mechanisms have been postulated for SARS CoV-2-associated cardiovascular damage including direct myocardial injury, systemic inflammation, hypoxemia, coronary thrombosis and drug-induced cardiac damage. Special attention should be given towards patients of SARS CoV-2 with concurrent cardiovascular diseases. Knowledge of the injury caused by SARS CoV-2 to the cardiovascular system and the mechanisms behind it is of the utmost importance to reduce the morbidity and mortality of these patients by treating them in time.
How to cite this article:
Kumar N, Kumar S, Vardhan H, Lakhtakia L, Daga MK. Cardiovascular Manifestations of SARS CoV-2: A Review. J Adv Res Med 2020; 7(2): 1-10.
Wu JT, Leung K, Leung G. Nowcasting and forecasting the potential domestic and international spread of the
-nCoV outbreak originating in Wuhan, China: a modelling study. Lancet. 2020; 395(10225): 689-697.
Lauer SA, Grantz KH, Bi Q et al. The incubation period of coronavirus disease 2019 (COVID-19) from publicly
reported confirmed cases: estimation and application. Ann Intern Med 2020; 172(9): 577-582.
Wu Z, McGoogan JM. Characteristics of and important lessons from the coronavirus disease 2019 (COVID-19)
outbreak in China: summary of a report of 72 314 cases from the Chinese Center for Disease Control and
Prevention. JAMA 2020; 323(13): 1239-1242.
Huang C, Wang Y, Li X et al. Clinical features of patients infected with 2019 novel coronavirus in
Wuhan, China. Lancet 2020; 395(10223): 497-506.
Chen N, Zhou M, Dong X et al. Epidemiological and clinical characteristics of 99 cases of 2019 novel
coronavirus pneumonia in Wuhan, China: a descriptive study. Lancet 2020; 395(10223): 507-513.
Jatin M, Jonathan H et al. The Natural History, Pathobiology, and Clinical Manifestations of SARSCoV-
Infections. J Neuroimmune Pharmacol 2020; 21: 1-28.
Turner, A, Hiscox, JA, Hooper NM. ACE2: from vasopeptidase to SARS virus receptor. Trends Pharmacol
Sci 2004 Jun; 25(6): 291–294.
Ferrario CM, Chappell MC, Tallant EA. Counterregulatory actions of angiotensin-(1–7). Hypertension 1997; 30(3
Pt 2): 535-541.
Peiro S. Moncada S. Substituting angiotensin-(1–7) to prevent lung damage in SARS-CoV-2 infection?
Circulation 2020; 141(21): 1665–1666.
Pedersen SF, Ho YC. SARS-CoV-2: a storm is raging. J Clin Invest 2020; 130(5): 2202-2205.
Tisoncik JR, Korth MJ, Simmons CP. Into the eye of the cytokine storm. Microbiol. Mol Biol Rev 2012; 76
Guo YR, Cao QD, Hong ZS et al. The origin, transmission and clinical therapies on coronavirus disease 2019
(COVID-19) outbreak - an update on the status. Mil Med Res 2020; 7(1): 11.
Kaplan B, Sulentic C, Haggerty H, Holsapple M. Toxic Responses of the Immune System. In Barnes and Davis
(9th Eds). Toxicology (Ch 12). New York: McGraw Hill Education.
Li B, Yang J, Zhao F et al. Prevalence and impact of cardiovascular metabolic diseases on COVID-19 in
China. Clin Res Cardiol 2020; 109(5): 531-538.
Miller CC, Zarubaev VV et al. Influenza epidemics and acute respiratory disease activity are associated with
a surge in autopsy-confirmed coronary heart disease death: results from 8 years of autopsies in 34,892
subjects. Eur Heart J 2007; 28(10): 1205-1210.
Nguyen JL, Yang W, Ito K, Matte TD, Shaman J, Kinney PL. Seasonal influenza infections and
cardiovascular disease mortality. JAMA Cardiol 2016; 1(3): 274-281.
Smeeth L, Thomas SL, Hall AJ, Hubbard R, Farrington P, Vallance P. Risk of myocardial infarction and stroke
after acute infection or vaccination. N Engl J Med 2004; 351(25): 2611-2618.
Bone RC, Grodzin CJ, Balk RA. Sepsis: a new hypothesis for pathogenesis of the disease process. Chest 1997;
Dong L,Hu S, Gao J, Discovering drugs to treat coronavirus disease 2019 (COVID- 19). Drug Discov
Ther 2020; 14 (1): 58-60.
Mueck W, Kubitza D, Becka M, Co-administration of rivaroxaban with drugs that share its elimination
pathways: pharmacokinetic effects in healthy subjects. Br J Clin Pharmacol 2013; 76(3): 455-466.
Yu CM, Wong RS, Wu EB, Kong SL, Wong J. Cardiovascular complications of severe acute respiratory syndrome. Postgrad Med 2006; 82(964): 140-144.
Sarkisian L, Saaby L, Poulsen TS, Gerke O, Jangaard N. Clinical characteristics and outcomes of patients
with myocardial infarction, myocardial injury, and nonelevated troponins. Am J Med 2016; 129(4): 446-
Huang C, Ren YL, Zhao J, Hu Y. Clinical features of patients infected with 2019 novel coronavirus in
Wuhan, China. Lancet 2020; 395(10223): 497-506.
De Vries. SARS-cov-2/COVID-19: a primer for cardiologists. Neth Heart J 2020; 28(7-8): 366-383.
Wang D, Hu B, Hu C et al. Clinical characteristics of 138 hospitalized patients with 2019 Novel Coronavirus-
Infected Pneumonia in Wuhan, China. JAMA 2020; 323(11): 1061-1069.
Lippi G, Lavie CJ. Sanchis-Gomar F. Cardiac troponin I in patients with coronavirus disease 2019 (COVID-19):
Evidence from a meta-analysis. Prog Cardiovasc Dis 2020; 63(3): 390-391.
Clerkin KJ, Fried JA, Raikhelkar J et al. Coronavirus disease 2019 (COVID-19) and cardiovascular disease.
Circulation 2020; 141(20): 1648-1655.
Xu Z, Shi L, Wang Y et al. Pathological findings of COVID-19 associated with acute respiratory distress syndrome. Lancet Respir Med 2020; 8: 420-422.
Tavazzi G, Pellegrini C, Maurelli M et al. Myocardial localization of coronavirus in COVID-19 cardiogenic
shock. Eur J Heart Fail 2020; (22)5: 911-915.
Wong CK, Lam CWK, Wu AKL et al. Plasma inflammatory cytokines and chemokines in severe acute respiratory syndrome. Clin Exp Immunol 2004; 136: 95-103.
Saini HK, Xu YJ, Zhang M et al. Role of tumour necrosis factor- alpha and other cytokines in ischemiareperfusion-induced injury in the heart. Exp Clin Cardiol 2005; 10: 213-222.
He XW, Lai JS, Cheng J et al. Impact of complicated myocardial injury on the clinical outcome of severe
or critically ill COVID-19 patients. Zhonghua Xin Xue Guan Bing Za Zhi 2020; 48(6): 456-460.33. Kwong JC, Schwartz KL, Campitelli MA et al. Acute myocardial infarction after laboratory-confirmed
influenza infection. N Engl J Med 2018; 378(4): 345-353.
Shi S, Qin M, Shen B et al. Association of cardiac injury with mortality in hospitalized patients with
COVID-19 in Wuhan, China. JAMA Cardiol 2020; 5(7): 802-810.
Guo T, Fan Y, Chen M, et al. Cardiovascular implications of fatal outcomes of patients with coronavirus disease 2019 (COVID-19). JAMA Cardiol 2020; 5(7): 811-818.
Arentz M, Yim E, Klaff L, Lokhandwala S, Riedo F, Chong M, Lee M. Characteristics and Outcomes of 21 Critically Ill Patients With COVID-19 in Washington State. JAMA 2020; 323(16): 1612-1614.
Madjid M et al. Influenza epidemics and acute respiratory disease activity are associated with a surge
in autopsy-confirmed coronary heart disease death: results from 8 years of autopsies in 34,892 subjects. Eur
Heart J 2007; 28: 1205-1210.
38. Bangalore S et al. ST-segment elevation in patients with COVID-19 – a case series. N Engl J Med 2020;
Stefanini GG et al. ST-elevation myocardial infarction in patients with COVID-19: clinical and angiographic
outcomes. Circulation 2020; 141: 2113-2116.
Libby P, Tabas I, Fredman G, Fisher EA. Inflammation and its resolution as determinants of acute coronary
syndromes. Circ. Res. 2014 Jun;114:1867–1879.
Varga Z et al. Endothelial cell infection and endotheliitis in COVID-19. Lancet 2020; 395(10234): 1417-1418.
De Rosa S et al. Reduction of hospitalizations for myocardial infarction in Italy in the COVID-19 era. Eur
Heart J 2020; 41(22): 2083-2088.
Baldi E et al. Out-of-hospital cardiac arrest during the COVID-19 outbreak in Italy. N Engl J Med 2020; 383(5):
Zeng JH, Liu YX, Yuan J et al. First case of COVID-19 infection with fulminant myocarditis complication: a
case report and insights. Infection 2020; 1-5.
Hu H, Ma F, Wei X, Fang Y. Coronavirus fulminant myocarditis saved with glucocorticoid and human
immunoglobulin. Eur Heart J 2020; 190.
Hua A, O’Gallagher K, Sado D, Byrne J. Life-threatening cardiac tamponade complicating myo-pericarditis in
COVID-19. Eur Heart J 2020; 41(22): 2130.
Ruan QR, Yang K, Wang WX, Jiang LY, Song JX. Clinical predictors of mortality due to COVID-19 based on an
analysis of data of 150 patients from Wuhan, China. Intensive Care Med 2020; 46(5): 846-848.
Hui H, Zhang Y, Yang X et al. Clinical and radiographic features of cardiac injury in patients with 2019 novel
coronavirus pneumonia. Cureus 2020; 12(5): e8021.
Yu CM, Wong RS, Wu EB et al. Cardiovascular complications of severe acute respiratory syndrome.
Postgrad Med J 2006; 82(964): 140-144.
Xie Y, Wang X, Yang P, Zhang S. COVID-19 complicated by acute pulmonary embolism. Radiology: Cardiothoracic Imaging. 2020 Mar 16; 2(2): e200067
Danzi GB, Loffi M, Galeazzi G, Gherbesi E. Acute pulmonary embolism and COVID-19 pneumonia: a
random association? Eur Heart J 2020; 41(19): 1858.
Zhou F, Yu T, Du R, et al. Clinical course and risk factors for mortality of adult inpatients with COVID-19 in
Wuhan, China: a retrospective cohort study. Lancet 2020; 395(10229): 1054-1062.
Tang N, Li D, Wang X, Sun Z. Abnormal coagulation parameters are associated with poor prognosis in
patients with novel coronavirus pneumonia. J Thromb Haemost 2020; 18(4): 844-847.
Shorr AF, Thomas SJ, Alkins SA, Fitzpatrick TM et al. Ddimer correlates with proinflammatory cytokine levels
and outcomes in critically ill patients. Chest 2002; 121: 1262-1268.
Gunther A, Mosavi P, Heinemann S et al. Alveolar fibrin formation caused by enhanced procoagulant
and depressed fibrinolytic capacities in severe pneumonia. Comparison with the acute respiratory
distress syndrome. Am J Respir Crit Care Med 2000; 161(2 Pt 1): 454-462.
Bone RC, Grodzin CJ, Balk RA. Sepsis: a new hypothesis for pathogenesis of the disease process. Chest 1997;
Shanghai Clinical Treatment Expert Group for COVID-19. [Comprehensive treatment and management of
coronavirus disease 2019: expert consensus statement from Shanghai]. Chin J Infect 2020; 1-10.
Tang N, Bai H, Chen X et al. Anticoagulant treatment is associated with decreased mortality in severe
coronavirus disease 2019 patients with coagulopathy. J Thromb Haemost 2020; 18: 1094-1099.
Li T, Lu H, Zhang W. Clinical observation and management of COVID-19 patients. Emerg Microbes Infect 2020;
Barnes GD, Burnet A, Allen A et al. Thromboembolism and anticoagulant therapy during the COVID‑19
pandemic: interim clinical guidance from the anticoagulation forum. J Thromb Thrombolysis 2020;
Kwong JC et al. Acute myocardial infarction after laboratory-confirmed influenza infection. N Engl J
Med 2018; 378: 345-353.
Arentz M, Yim E, Klaff L et al. Characteristics and outcomes of 21 critically ill patients with COVID-19 in
Washington State. JAMA 2020; 323(16): 1612-1614.
Driggin E, Madhavan M, Bikdeli M, Chuich T, Laracy J, Bondi-Zoccai G. Cardiovascular considerationsforpatients, health care workers, and health systems during the coronavirus disease 2019 (COVID-19) pandemic. J Am Coll Cardiol 2020; 75(18): 2352-2371.
Zhou F, Yu T, Du R, Fan G, Liu Y, Liu Z et al. Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study. Lancet 2020; 395(10229): 1054-1062.
Sinkey RG, Rajapreyar I, Robbins L, Dionne-Odom J, Pogwizd S. Heart failure with preserved ejection
fraction in a postpartum patient with superimposed preeclampsia and COVID-19. AJP Rep 2020; 10(2):
Patel V, Shah S, Verma S, Oudit G. Epicardial adipose tissue as a metabolic transducer: role in heart failure
and coronary artery disease. Heart Fail Rev 2017; 22(6): 889-902.
Tavazzi G, Pellegrini C, Maurelli M, Belliato M, Sciutti F, Bottazzi A. Myocardial localization of coronavirus
in COVID- 19 cardiogenic shock. Eur J Heart Fail 2020; 22(5): 911-915.
Dawei Wang, Bo Hu, Chang Hu, Fangfang Zhu, Xing Liu, Zhiyong Peng, Clinical characteristics of 138
hospitalized patients with 2019 novel coronavirus–infected pneumonia in Wuhan, China, JAMA 2020;
Giudicessi JR , Noseworthy PA, Friedman PA, Ackerman MJ. Urgent guidance for navigating and circumventing
the QTc prolonging and torsadogenic potential of possible pharmacotherapies for coronavirus disease
(COVID-19). Mayo Clin Proc 2020; 95(6): 1213-1221.
Somer M, Kallio J, Pesonen U, Pyykkö K et al. Influence of hydroxychloroquine on the bioavailability of oral
metoprolol. Br J Clin Pharmacol 2000; 49(6): 549-555.
Mulangu S, Dodd L, Davey R, Mbaya O, Proschan M, P.W. Grp, P.C.S. Team, A. Randomized, Controlled trial
of Ebola virus disease therapeutics. N Engl J Med 2019; 381(24): 2293-2303.
Yang J, Zheng Y, Gou X et al. Prevalence of comorbidities in the novel Wuhan coronavirus (COVID-19) infection: a systematic review and meta-analysis. Int J Infect Dis 2020; 94: 91-95.
Grasselli G, Zangrillo A, Zanella A et al. Baseline characteristics and outcomes of 1591 patients infected
With SARS-CoV- 2 admitted to ICUs of the Lombardy Region, Italy. JAMA 2020; 323(16): 1574-1581.
Zheng Y, Ma Y, Zhang J, Xie X. COVID-19 and the cardiovascular system. Nat Rev Cardiol 2020; 17: 259-
Chan JW, Ng CK, Chan YH et al. Short term outcome and risk factors for adverse clinical outcomes in adults
with severe acute respiratory syndrome (SARS). Thorax 2003; 58: 686-689.
Badawi A, Ryoo SG. Prevalence of comorbidities in the Middle East respiratory syndrome coronavirus
(MERS-CoV): a systematic review and meta-analysis. Int J Infect Dis 2016; 49: 129-133.
Fielding B. MERS-CoV: Understanding the Latest Human Coronavirus Threat. Viruses 2018; 10(2): 93.
Ghatrif M, Cingolani O, Lakatta EG. The dilemma of coronavirus disease 2019, aging, and cardiovascular
disease: insights from cardiovascular aging science. JAMA Cardiol 2020; 5(7): 747-748.
Corrales-Medina VF, Alvarez KN, Weissfeld LA et al. Association between hospitalization for pneumonia
and subsequent risk of cardiovascular disease. JAMA 2015; 313(3): 264-274.
Wu Q, Zhou L, Sun X et al. Altered lipid metabolism in recovered SARS patients twelve years after infection.
Sci Rep 2017; 7(1): 9110.
Guo L, Han Y, Li J et al. Long-term outcomes in patients with severe acute respiratory syndrome treated with
oseltamivir: a 12- year longitudinal study. Int J Clin Exp Med 2019; 12(10): 12464-12471.
Masclans JR, Roca O, Munoz X et al. Quality of life, pulmonary function, and tomographic scan
abnormalities after ARDS. Chest 2011; 139(6): 1340-1346.
Thille AW, Esteban A, Fernandez-Segoviano P et al. Chronology of histological lesions in acute respiratory
distress syndrome with diffuse alveolar damage: a prospective cohort study of clinical autopsies. Lancet
Respir Med 2013; 1(5): 395-401.
Desai SR, Wells AU, Rubens MB, Evans TW, Hansell DM. Acute respiratory distress syndrome: CT abnormalities
at long-term follow-up. Radiology 1999; 210(1): 29-35.
Burnham EL, Janssen WJ, Riches DW, Moss M, Downey GP. The fibroproliferative response in acute respiratory
distress syndrome: mechanisms and clinical significance. Eur Respir J 2014; 43(1): 276-285.
Scott D. Collum, Javier Amione-Guerra, Ana S. Cruz-Solbes, Amara DiFrancesco Pulmonary Hypertension
Associated with Idiopathic Pulmonary Fibrosis: Current and Future Perspectives. Can Respir J 2017; 12: 1-12.
Copyright (c) 2020 Journal of Advanced Research in Medicine (E-ISSN: 2349-7181 & P-ISSN: 2394-7047)
This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.