Case by Case, a Portrait Emerges of COVID-19’s Cardiovascular Fingerprint

Strange thromboses, troponin spikes in the absence of coronary disease, Kawasaki-like illness, strokes in the young, and an uptick in Takotsubo—these are but a few of the unusual cardiovascular manifestations of COVID-19 reported by researchers and clinicians scrambling to put together a picture of the disease.

This wide swath is evident in a collection of JACC: Case Reports papers published online in recent weeks, which have been arriving in droves since the journal issued a call for cases in April.

“When COVID-19 was declared a pandemic we were aware that it would take a few months until we had large registries or pharmaceutical trials being reported,” Julia Grapsa, MD, PhD (Guys and St Thomas NHS Trust, London, England), editor-in-chief of the journal, told TCTMD. “We then realized that it would be important to collect evidence of the COVID-19 cardiovascular manifestations.”

It swiftly became clear that this viral illness could have particularly complicated and devastating interactions with the cardiovascular system in terms of systemic clotting, pulmonary emboli, stent thrombosis, cardiac injury, arterial inflammation, STEMI mimics, and endothelial damage. Drugs tested against the virus have included antithrombotics and anti-inflammatories, while long-standing antivirals have prompted cardiac arrhythmias. Commonly used cardiac medications have been suspected mediators of disease, along with a range of CV risk factors, including hypertension, stress, and obesity. Many, if not all of these, have been captured in the journal series.

Still others document even more curious scenarios and associated advice, Grapsa noted. What of patients with left ventricular assist devices or a prior heart transplant? Or those infected not only by SARS-CoV-2 but also influenza or HIV? And how might angiography be performed in a prone patient? What can be done for a patient with Brugada syndrome type 1 in the context of fever and arrhythmias without underlying myocardial abnormalities? “We were really surprised to see the variety of the manifestations of COVID,” she said.

An astounding 550 cases have been submitted as part of the journal’s call for papers and, after careful vetting, a representative slice were chosen for publication, said Grapsa. All will be published in the July 15, 2020, issue of JACC: Case Reports.

When COVID-19 was declared a pandemic we were aware that it would take a few months until we had large registries or pharmaceutical trials being reported. Julia Grapsa

Crediting the journal’s social media editor, Estefania Oliveros, MD (Mount Sinai Hospital, New York, NY), for the initial idea, Grapsa said their goal was to share what was happening in different countries in terms of the pandemic and patient care.

But they did not want to sacrifice quality for quantity. This, she said, was why they accepted only case reports “where the ‘cause and causation’ relationship was crystal clear” and whose authors had thoroughly documented how they came to a diagnosis (eg, through imaging and histology). Outside experts were brought in to give insight on the “possible pathophysiologic connection” with COVID-19, she explained.

Thromboembolic events, such as pulmonary embolism, represented the largest slice of submissions. Yet, to provide a comprehensive picture, the editorial board selected a few of the best cases across four distinct categories: arrhythmias, thromboembolic events, heart failure, and coronary events.

“We wanted to have a 360 view of what’s happening,” she said.

Important, too, was the need to put the cases in context when, across the world and across online platforms, there was a deluge of clinical experiences, Grapsa observed. “It was a constant chase of: what’s happening out there? Has it been reported before?” The JACC: Case Reports team tried, when possible, to crosslink papers with information about ongoing trials and to collaborate with the JACC sister journals to draw connections with other articles in the pipeline.

Ultimately, they chose to publish 32 case reports as well as several viewpoints, with an overall acceptance rate of 6% to 8%.

Among the editorials, said Grapsa, there is a piece on sex differences in COVID-19 as well as first-person accounts from Italy, the United Kingdom, and—soon to come—New York City, which speak to the theme: “We are all in this together.” Another useful paper reviewed mechanical ventilation for cardiologists, she added. “All my trainees started reading that when we were deployed in the ICU, because for us as cardiologists, we haven’t [been] working as intensivists ever since we did our residency.”

Grapsa told TCTMD she saw positive effects on her own everyday practice. “In the morning huddle with my colleagues in the intensive care unit, we would discuss the interesting clinical cases and we would start becoming aware that a COVID-19 patient may suffer myocarditis, Takotsubo, or thromboembolic events with right heart involvement,” she recalled. As an imager, she was often asked to quantify ventricular performance ahead of extracorporeal membrane oxygenation weaning.

JACC: Case Reports will continue to publish COVID-19 manuscripts that present new knowledge and are well written, she said. And in August, the journal is collaborating with the Society for Cardiovascular Angiography and Interventions for another special issue, this time focused on mechanical complications of acute coronary events stemming from delayed presentation during the COVID-19 lockdown.