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July 27, 2020

Coronavirus Disease 2019 (COVID-19) and the Heart—Is Heart Failure the Next Chapter?

Author Affiliations
  • 1Division of Cardiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
  • 2Deputy Editor, JAMA Cardiology
  • 3Ahmanson-UCLA Cardiomyopathy Center, David Geffen School of Medicine, University of California, Los Angeles
  • 4Section Editor, JAMA Cardiology
JAMA Cardiol. Published online July 27, 2020. doi:10.1001/jamacardio.2020.3575

Multiple data sets now confirm the increased risk for morbid and mortal complications due to coronavirus disease 2019 (COVID-19) in individuals with preexisting cardiovascular diseases including hypertension, coronary artery disease, and heart failure.1,2 These salient observations have strengthened preventive strategies and undoubtedly have resulted in lives saved. Although episodes of clinical myocarditis have been suspected and a few cases have been reported in the literature,3 direct cardiac involvement due to the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has been difficult to confirm.

In this issue of JAMA Cardiology, Linder and colleagues4 report on 39 autopsy cases of patients with COVID-19 in whom pneumonia was the clinical cause of death in 35 of 39 (89.7%). While histopathologic evaluation did not meet criteria seen in acute myocarditis, there was evidence of virus present in the heart in 24 of 39 patients (61.5%) with a viral load more than 1000 copies per microgram of RNA in 16 of 24 patients (66.7%). Evidence of active viral replication was also noted. In situ hybridization suggested that the most likely localization of the viral infection was in interstitial cells or macrophages infiltrating the myocardial tissue rather than localization in the myocytes themselves. Further using a panel of 6 proinflammatory genes, the investigators demonstrated increased activity among hearts with evidence of viral infection compared with hearts with no SARS-CoV-2 viral infection detected.4 These new findings provide intriguing evidence that COVID-19 is associated with at least some component of myocardial injury, perhaps as the result of direct viral infection of the heart.