COVID-19 and Cardiovascular Disease:

The Perfect Partner in Crime

Yoga Waranugraha, MD, FIHA

Cardiology and Vascular Medicine Department
Faculty of Medicine – Universitas Brawijaya
Introduction
Wang C, el al. The Lancet, 2020; 395(10223), 470-473.
 SARS-CoV-2

• β coronavirus
• Enveloped, single-stranded,
positive-sense RNA virus
• Diameter of 60–140 nm.
• Causes coronavirus disease
2019 (COVID-19)

Zhang Y, et al. Biomedicine & Pharmacotherapy, 2020; 110195

Pathogenesis
Li X, et al. Journal of Pharmaceutical Analysis, 2020; 0(2), 102-108.
Siddiqi HK & Mehra MR. The Journal of Heart and Lung Transplantation, 2020; 39(5), 405.
Key symptoms, and
biochemical and
radiological features of the
clinical course of COVID-19

Guzik TJ, et al. Cardiovascular research. 2020

COVID-19 and CVD:
Which Link?
Cardiovascular
involvement in COVID-19:
Key manifestations and
hypothetical mechanisms

Guzik TJ, et al. Cardiovascular research. 2020

The Perfect Partner in Crime
 “The Deadly Combination”

UNDERLYING
CARDIOVASCULAR
CARDIOVASCLAR COVID-19 MANIFESTATIONS
DISEASES
 Impact of Hypertension on Mortality of COVID-19

Waranugraha Y, et al. 2020. Manuscript is under Review

 Impact of CAD on Mortality of COVID-19

Waranugraha Y, et al. 2020. Manuscript is under Review

 Impact of Heart Failure on Mortality of COVID-19

Waranugraha Y, et al. 2020. Manuscript is under Review

Possible Mechanism of
Myocardial Injury in
COVID-19
 Myocardial Injury & Myocardial Infarction
• Myocardial injury
• Evidence of elevated cardiac troponin values (cTn) with at least one value above the 99th percentile upper
reference limit (URL).
• The myocardial injury is considered acute if there is a rise and/or fall of cTn values.

• Myocardial infarction
• Acute myocardial injury with clinical evidence of acute myocardial ischaemia.
• Detection of a rise and/or fall of cTn values with at least one value above the 99th percentile URL and at least
one of the following:
• Symptoms of myocardial ischemia;
• New ischemic ECG changes;
• Development of pathological Q waves;
• Imaging evidence of new loss of viable myocardium or new regional wall motion abnormality in a pattern consistent with an
ischemic etiology;
• Identification of a coronary thrombus by angiography or autopsy.

Thygesen K, et al. Journal of the American College of Cardiology, 2018; 72(18), 2231-2264.
 Impact of Cardiac Injury on Mortality

Santoso A, et al. The American Journal of Emergency Medicine. 2020

 Cardiac injury was associated with an increased need for ICU
care and severe COVID-19

Santoso A, et al. The American Journal of Emergency Medicine. 2020

Arrhythmia in COVID-19: Possible Mechanisms

UNDERLYING CARDIO-
SIDE
CARDIO- VASCULAR EFFECTS OF
COMORBIDITIES MANIFESTATIONS
VASCLAR SEVERAL
OF COVID-19
DISEASES DRUGS
Borba MGS, et al. JAMA network open, 3(4), e208857-e208857.
 Impact of Arrhythmia on Mortality of COVID-19

Waranugraha Y, et al. 2020. Manuscript is under Review

ACE inhibitors/ARBs and COVID-19
 Basic pathobiology of SARS-
CoV-2 infection and possible
treatment strategies

Guzik TJ, et al. Cardiovascular research. 2020

Alexandre J, et al. Annales d'Endocrinologie. 2020
ACE inhibitors/ARBs for CVD during COVID-19
Pandemic:

Friend or Foe?
 Initiation, Continuation, or Withdrawal of ACE Inhibitors/ARBs and Outcomes in
Patients Hospitalized With Heart Failure With Reduced Ejection Fraction

Gilstrap LG, et al. Journal of the American Heart Association, 2017; 6(2), e004675.
Continuation of RAAS antagonists for those patients who
are currently prescribed such agents for indications for
which these agents are known to be beneficial, such as
heart failure, hypertension, or ischemic heart disease.
 The effect of ACEIs/ARBs on the positive test for COVID-19

Waranugraha Y, et al. 2020. Manuscript in Preparation

 The effect of ACEIs/ARBs on the mortality of COVID-19 patients

Waranugraha Y, et al. 2020. Manuscript in Preparation

Take Home Messages
• COVID-19 has several cardiovascular
manifestations.
• The presence of cardiovascular diseases
increase the mortality of COVID-19 patients
→ “The Perfect Partner in Crime”.
• ACE inhibitors and ARBs have to be
continued in patients with specific
indications (hypertension, coronary artery
disease, and heart failure).
MATUR SEMBAH NUWUN…