28 Jul MRI Study Revealed Ongoing Cardiac Inflammation in Patients Recovering from COVID-19
MedicalResearch.com Interview with:
Dr. Puntmann
Assoc. Prof. Dr. Valentina Puntmann, MD, PhD, FRCP
Deputy Head
Goethe CVI Fellowship Programme Lead
Consultant Physician, Cardiologist and Clinical Pharmacologist
Institute for Experimental and Translational Cardiovascular Imaging
DZHK Centre for Cardiovascular Imaging – Goethe CVI
Department of Cardiology, Division of Internal Medicine
University Hospital Frankfurt, Germany
MedicalResearch.com: What is the background for this study?
Response: Patients who recently recovered from COVID19 have been identified through the testing centre and invited to be screened for cardiac involvement with MRI. Importantly, they have not come to us because of having heart problems. In fact, none of them thought that they had had anything wrong with the heart. They were mostly healthy, sporty and well prior to their illness. A considerable proportion had been infected while on skiing vacations.
MedicalResearch.com: What are the main findings?
Response: We found evidence of ongoing inflammation within the heart muscle, as well as of the heart’s lining in a considerable majority of patients (78 of a total of 100 patients). These findings are also known as myocarditis and pericarditis, respectively. The patients and ourselves and were both surprised by the intensity and prevalence of these findings, and that they were still very pronounced even though the original illness had by then been already a few weeks away.
I should probably emphasise that our set of heart measurements, the Goethe CVI Approaches, are known to be very sensitive to detect cardiac inflammation. We have made a lot of validation work and experience with these tools in other heart conditions, where inflammation plays a role in the development of heart disease, for instance cardio-oncology or lupus myocarditis. However, we – like many others – thought of COVID19 disese as a primarily respiratory illness. Once the reports of severe autoimmune reactions, such as the ‘cytokine storm’ and similar, were first mentioned, we came to think that the heart would have also been involved, because myocarditis is essentially an autoimmune disease that follows an initial trigger, such as infection.
MedicalResearch.com: What should readers take away from your report?
Response: There are several important aspects to consider:
Firstly, the fact that 78% of ‘recovered’ had evidence of an ongoing heart involvement means that heart will be involved in a majority of patients, even if the heart does not scream out with the classical ‘heart symptoms’ such as anginal chest pain during the acute COVID19 illness.
Secondly, the absence of heart-specific symptoms is quite important. It is typical for inflammatory heart conditions to remain silent (subclinical) for many years, before they give themselves away, usually when heart is already pretty knackered and patients develop heart failure. In my view, the relatively ‘clear onset of COVID19 illness’ provides an opportunity – which we often do not have with other conditions – to take a proactive action and to look for heart involvement early, i.e. within a few weeks from recovery.
Thirdly, while we need to proactively look for the evidence of cardiac damage due to the inflammation, it matters how we do this. One way could be a troponin blood test. However, troponin is a test to diagnose acute complications of coronary artery disease such as the ‘heart attack’. It has never been validated for the use in myocarditis, meaning, the cut-off values for heart attack cannot be used for myocarditis. If we use the same cut-off values, we would likely send home a lot of patients that actually have a serious heart disease. Similarly, echocardiography, although widely available, is not a sensitive test for myocardial inflammation, because it simply cannot see inside the heart muscle. More often than not, pumping function remains normal in these early stages (as also shown in our patients). If impaired, how would one know it is not due to an old damage? We perform echo in parallel to cardiac MRI in all of our patients, so we have evidence to this claim. Worse even, in some countries doctors would only rely on invasive heart biopsies to confirm the inflammation, which is an invasive test, performed in a catheter lab, are expensive and not without complications. Ther evidence that biopsies help to improve treatment. is also missing.
MedicalResearch.com: What recommendations do you have for future research as a result of this work?
Response: COVID19 infection is an unsolved problem affecting the population worldwide on an unprecedented scale. Cardiac involvement may not be the most visible part of the acute illness, however, it is there in a considerable proportion. While we do not yet have the direct evidence for late consequences yet, such as development of the heart failure, which can be directly attributed to COVID19, it is quite possible that in a few years, this burden will be enormous, based on what we learnt from other viral conditions that similarly affect the heart (cardiotropic vira, swine flu, etc). I can hardly see it justified to wait for the outcome data first, as by then we might be overwhelmed not only by seriousness of the acute illness, but also with its chronic complications, ie. heart failure.
Unfortunately, doctors are currently not very good at taking proactive therapeutic action prior to the development of heart failure, simply because they do not know how to look for signs early enough and many wold not know that cardiac MRI can help with that. The reason for this is that not many will have an easy access to cardiac MRI, and even less, would have the training to make a good use of its findings. For example, even in Germany, training in cardiac MRI has only become a part of the national Cardiology training curriculum last year. Saying this, the truth is that the cardiac MRI experts tend to be very academical and overcomplicate the scanning procedures. With Goethe CVI Approaches we made tremendous efforts to boil down the examination and its messages to the essential information, which makes a difference for the patients. Our scans last 15-20 min.
Early diagnosis is important because there is a good chance that early treatment will reduce the relentless course of inflammatory damage or even halt it. We could use a number of existing medications as well as test a number of potential candidates. However, for all this to be implemented in practice, we need further studies most urgently and we are inviting any interested parties to join us in our efforts to get this done.
We now have the diagnostic means to detect cardiac inflammation in the heart and we need to use them in every day practice. Using Goethe CVI Approaches will allow to raise our game against COVID19 and proactively develop efficient cardioprotective treatments. Till we have effective means of protecting from the infection self (i.e. vaccination), we must act swiftly and within the means we have at hand.
MedicalResearch.com: Is there anything else you would like to add?
Response: Here are the main 3 messages:
- The heart may not be screaming out for help in its classical ways, i.e. no symptoms like angina, and yet it is in a serious trouble as a part of COVID19 disease.
- We need to tune in, meaning we need to use diagnostic tools that can detect this silent pathology, and realise that not every tool is good for this, it has to be cardiac MRI.
- We need to make the efforts to make MRI machines available for cardiac indications because it prognostically matters most what happens with the heart.
Disclosures (as in the paper):
German Ministry of Education and Research via the German Centre for Cardiovascular Research (DZHK) partner site RheinMain.
Deutsche Herzstiftung e.V. Frankfurt am Main, Germany
Bayer AG Leverkusen, Germany.
Cardio-Pulmonary Institute (CPI), EXC 2026, Project ID: 390649896.
Citation:
Puntmann VO, Carerj ML, Wieters I, et al. Outcomes of Cardiovascular Magnetic Resonance Imaging in Patients Recently Recovered From Coronavirus Disease 2019 (COVID-19). JAMA Cardiol. Published online July 27, 2020. doi:10.1001/jamacardio.2020.3557
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Last Updated on July 28, 2020 by Marie Benz MD FAAD