Turkiye Klinikleri Cardiovascular Sciences

.: ORIGINAL RESEARCH
Cardiac Involvement is the Reason for Persistent Dyspnea in Post COVID-19 Patients without Pulmonary Sequelae: A Retrospective Study
COVID-19 Geçiren Pulmoner Sekeli Olmayan Hastalarda Kalıcı Dispne Nedeni Kardiyak Tutulumdur: Retrospektif Çalışma
Tuğçe ÇÖLLÜOĞLUa, Murat ACATb, Ömer ÖZSARAÇc, Yeşim AKINa, Orhan ÖNALANa
aDepartment of Cardiology, Karabük University Faculty of Medicine, Karabük, Türkiye
bDepartment of Chest Disease, Karabük University Faculty of Medicine, Karabük, Türkiye
cDepartment of Nuclear Medicine, Karabük University Faculty of Medicine, Karabük, Türkiye
Turkiye Klinikleri J Cardiovasc Sci. 2022;34(2):46-54
doi: 10.5336/cardiosci.2022-88692
Article Language: EN
Full Text
ABSTRACT
Objective: Several forms of cardiovascular involvement have been described in acute coronavirus disease-2019 (COVID-19) infection and also it has been shown that acute infection is responsible for cardiac symptoms. However, the data on cardiac involvement and associated symptoms in chronic phase remains unclear. Recent evidence have shown that the reason for persistent dyspnea can be persistent cardiac dysfunction in post COVID-19 infection. The aim of our study was to investigate the relationship between persistent dyspnea and cardiac involvement in post COVID19 patients without pulmonary sequelae. Material and Methods: In our study, we recruited 30 post COVID-19 patients with dyspnea between January 2021 and July 2021. In all patients, the absence of pulmonary sequelae was detected with PFT and chest- CT. 2D-TTE, 2DSTE and MPS were performed for each case. Results: Left ventricular dysfunction was detected in 63.3% of patients and also 93.3% of patients had extensive abnormal GLS at 3 month follow-up. Of the patients, 33.3% had myocardial perfusion defect (MPD) and all MPDs were observed to be reversible defects. MPD was obviously seen in anterior wall (60%) and mid (20%) to apical (70%) segments. As compared with patients without MPD, patients with MPD had higher CK-MB (p: 0.016) and troponin I (p: 0.011), lesser PW thickness (p:0.020) and lower peak systolic strain rate at A2C view (p:0.031). Patients with NYHA III had more impaired GLS than patients with NYHA II (p:0.035). Conclusion: Our study suggests ischemic or nonischemic cardiac dysfunction may be associated with persistent dyspnea in post- COVID- 19 patients without lung sequelae.

Keywords: Dyspnea; post-acute COVID-19 syndrome; heart function tests
ÖZET
Amaç: Akut koronavirüs hastalığı-2019 [coronavirus disease2019 (COVID-19)] enfeksiyonunda çeşitli kardiyovasküler tutulum biçimleri tanımlanmıştır ve ayrıca akut enfeksiyonun kardiyak semptomlardan sorumlu olduğu gösterilmiştir. Bununla birlikte, kronik fazda kardiyak tutulum ve ilişkili semptomlar ile ilgili veriler belirsizliğini korumaktadır. Son kanıtlar, kalıcı dispne nedeninin COVID19 enfeksiyonu sonrası kalıcı kardiyak işlev bozukluğu olabileceğini göstermektedir. Çalışmamızın amacı, COVID-19 sonrası pulmoner sekeli olmayan hastalarda persistan dispne ile kardiyak tutulum arasındaki ilişkiyi araştırmaktır. Gereç ve Yöntemler: Çalışmamıza Ocak 2021 ile Temmuz 2021 arasında COVID-19 enfeksiyonu geçiren ve nefes darlığı devam eden 30 hastayı dahil ettik. Tüm hastalarda pulmoner sekel olmadığı SFT ve toraks BT ile tespit edildi. Her hastaya 2D- TTE, 2D- STE ve MPS yapıldı. Bulgular: 3 aylık takipte hastaların %63.3'ünde sol ventrikül disfonksiyonu saptandı ve hastaların %93.3'ünde yaygın anormal GLS vardı. Hastaların %33.3'ünde miyokard perfüzyon defekti (MPD) vardı ve tüm MPD'lerin geri dönüşümlü defekt olduğu gözlendi. MPD en sık olarak ön duvarda (%60) ve orta (%20) ile apikal (%70) segmentlerde görüldü.MPD'i olmayan hastalarla karşılaştırıldığında, MPD'li hastalarda daha yüksek CK-MB (p: 0.016) ve troponin I (p: 0.011), apikal iki boşluk görüntüde daha düşük PW kalınlığı (p:0.020) ve daha düşük tepe sistolik gerilim oranı vardı (p:0.031). NYHA III hastalarda NYHA II hastalara göre daha fazla bozulmuş GLS vardı (p:0.035). Sonuç: Çalışmamız, COVID-19 geçiren akciğer sekeli olmayan hastalarda iskemik veya non-iskemik kökenli kardiyak disfonksiyonun kalıcı dispne ile ilişkili olabileceğini düşündürmektedir.

Anahtar Kelimeler: Dispne; postakut COVID-19 sendromu; kardiyak fonksiyon testleri
REFERENCES:
  1. Puntmann VO, Carerj ML, Wieters I, Fahim M, Arendt C, Hoffmann J, et al. Outcomes of cardiovascular magnetic resonance imaging in patients recently recovered from coronavirus disease 2019 (COVID-19). JAMA Cardiol. 2020;5(11):1265-73. Erratum in: JAMA Cardiol. 2020;5(11):1308. [Crossref]  [PubMed]  [PMC] 
  2. Kamal M, Abo Omirah M, Hussein A, Saeed H. Assessment and characterisation of post-COVID-19 manifestations. Int J Clin Pract. 2021;75(3):e13746. [Crossref]  [PubMed]  [PMC] 
  3. Carfì A, Bernabei R, Landi F; Gemelli Against COVID-19 Post-Acute Care Study Group. Persistent symptoms in patients after acute COVID-19. JAMA. 2020;324(6):603-5. [Crossref]  [PubMed]  [PMC] 
  4. Salamanna F, Veronesi F, Martini L, Landini MP, Fini M. Post-COVID-19 syndrome: the persistent symptoms at the post-viral stage of the disease. A systematic review of the current data. Front Med (Lausanne). 2021;8:653516. [Crossref]  [PubMed]  [PMC] 
  5. Carvalho-Schneider C, Laurent E, Lemaignen A, Beaufils E, Bourbao-Tournois C, Laribi S, et al. Follow-up of adults with noncritical COVID-19 two months after symptom onset. Clin Microbiol Infect. 2021;27(2):258-63. [Crossref]  [PubMed]  [PMC] 
  6. Halpin SJ, McIvor C, Whyatt G, Adams A, Harvey O, McLean L, et al. Postdischarge symptoms and rehabilitation needs in survivors of COVID-19 infection: a cross-sectional evaluation. J Med Virol. 2021;93(2):1013-22. [Crossref]  [PubMed] 
  7. Bellan M, Soddu D, Balbo PE, Baricich A, Zeppegno P, Avanzi GC, et al. Respiratory and psychophysical sequelae among patients with COVID-19 four months after hospital discharge. JAMA Netw Open. 2021;4(1):e2036142. [Crossref]  [PubMed]  [PMC] 
  8. Guler SA, Ebner L, Aubry-Beigelman C, Bridevaux PO, Brutsche M, Clarenbach C, et al. Pulmonary function and radiological features 4 months after COVID-19: first results from the national prospective observational Swiss COVID-19 lung study. Eur Respir J. 2021;57(4):2003690. [Crossref]  [PubMed]  [PMC] 
  9. Nalbandian A, Sehgal K, Gupta A, Madhavan MV, McGroder C, Stevens JS, et al. Post-acute COVID-19 syndrome. Nat Med. 2021;27(4):601-15. [Crossref]  [PubMed]  [PMC] 
  10. Akhmerov A, Marbán E. COVID-19 and the heart. Circ Res. 2020;126(10):1443-55. [Crossref]  [PubMed] 
  11. Mitrani RD, Dabas N, Goldberger JJ. COVID-19 cardiac injury: Implications for long-term surveillance and outcomes in survivors. Heart Rhythm. 2020;17(11):1984-90. [Crossref]  [PubMed]  [PMC] 
  12. Culver BH, Graham BL, Coates AL, Wanger J, Berry CE, Clarke PK, et al; ATS Committee on Proficiency Standards for Pulmonary Function Laboratories. Recommendations for a Standardized Pulmonary Function Report. An official American Thoracic Society Technical Statement. Am J Respir Crit Care Med. 2017;196(11):1463-72. [Crossref]  [PubMed] 
  13. Lang RM, Badano LP, Mor-Avi V, Afilalo J, Armstrong A, Ernande L, et al. Recommendations for cardiac chamber quantification by echocardiography in adults: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. J Am Soc Echocardiogr. 2015;28(1):1-39.e14. [Crossref]  [PubMed] 
  14. Mor-Avi V, Lang RM, Badano LP, Belohlavek M, Cardim NM, Derumeaux G, et al. Current and evolving echocardiographic techniques for the quantitative evaluation of cardiac mechanics: ASE/EAE consensus statement on methodology and indications endorsed by the Japanese Society of Echocardiography. J Am Soc Echocardiogr. 2011;24(3):277-313. [Crossref]  [PubMed] 
  15. Yang H, Wright L, Negishi T, Negishi K, Liu J, Marwick TH. Research to practice: assessment of left ventricular global longitudinal strain for surveillance of cancer chemotherapeutic-related cardiac dysfunction. JACC Cardiovasc Imaging. 2018;11(8):1196-201. [Crossref]  [PubMed]  [PMC] 
  16. Chen Z, Li C, Li Y, Rao L, Zhang X, Long D, et al. Layer-specific strain echocardiography may reflect regional myocardial impairment in patients with hypertrophic cardiomyopathy. Cardiovasc Ultrasound. 2021;19(1):15. [Crossref]  [PubMed]  [PMC] 
  17. Huang L, Zhao P, Tang D, Zhu T, Han R, Zhan C, et al. Cardiac involvement in patients recovered from COVID-2019 identified using magnetic resonance imaging. JACC Cardiovasc Imaging. 2020;13(11):2330-9. [Crossref]  [PubMed]  [PMC] 
  18. Kravchenko D, Isaak A, Zimmer S, Mesropyan N, Reinert M, Faron A, et al. Cardiac MRI in patients with prolonged cardiorespiratory symptoms after mild to moderate COVID-19. Radiology. 2021;301(3):E419-E25. [Crossref]  [PubMed]  [PMC] 
  19. Özer S, Candan L, Özyıldız AG, Turan OE. Evaluation of left ventricular global functions with speckle tracking echocardiography in patients recovered from COVID-19. Int J Cardiovasc Imaging. 2021;37(7):2227-33. [Crossref]  [PubMed]  [PMC] 
  20. Li R, Wang H, Ma F, Cui GL, Peng LY, Li CZ, et al. Widespread myocardial dysfunction in COVID-19 patients detected by myocardial strain imaging using 2-D speckle-tracking echocardiography. Acta Pharmacol Sin. 2021;42(10):1567-74. [Crossref]  [PubMed]  [PMC] 
  21. Mahajan S, Kunal S, Shah B, Garg S, Palleda GM, Bansal A, et al. Left ventricular global longitudinal strain in COVID-19 recovered patients. Echocardiography. 2021;38(10):1722-30. [Crossref]  [PubMed]  [PMC] 
  22. Yang J, Liao X, Yin W, Wang B, Yue J, Bai L, et al; Study of 2019 Novel Coronavirus Pneumonia Infected Critically Ill Patients in Sichuan Province (SUNRISE) Group. Elevated cardiac biomarkers may be effective prognostic predictors for patients with COVID-19: a multicenter, observational study. Am J Emerg Med. 2020;39:34-41. [Crossref]  [PubMed]  [PMC] 
  23. Gorecka M, McCann GP, Berry C, Ferreira VM, Moon JC, Miller CA, et al; COVID-HEART investigators. Demographic, multi-morbidity and genetic impact on myocardial involvement and its recovery from COVID-19: protocol design of COVID-HEART-a UK, multicentre, observational study. J Cardiovasc Magn Reson. 2021;23(1):77. [Crossref]  [PubMed]  [PMC] 
  24. Çap M, Bilge Ö, Gündoğan C, Tatlı İ, Öztürk C, Taştan E, et al. SPECT myocardial perfusion imaging identifies myocardial ischemia in patients with a history of COVID-19 without coronary artery disease. Int J Cardiovasc Imaging. 2022;38(2):447-56. [Crossref]  [PubMed]  [PMC] 
  25. Drakos S, Chatzantonis G, Bietenbeck M, Evers G, Schulze AB, Mohr M, et al. A cardiovascular magnetic resonance imaging-based pilot study to assess coronary microvascular disease in COVID-19 patients. Sci Rep. 2021;11(1):15667. [Crossref]  [PubMed]  [PMC] 
  26. Lee LC, Zhihong Z, Hinson A, Guccione JM. Reduction in left ventricular wall stress and improvement in function in failing hearts using Algisyl-LVR. J Vis Exp. 2013;(74):50096. [Crossref]  [PubMed]  [PMC] 

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