Cardiac sequelae after COVID-19 recovery: a systematic review

Ramadan, Mohammad Said; Bertolino, Lorenzo; Zampino, Rosa; Durante-Mangoni, Emanuele

BACKGROUND: Coronavirus disease 2019 (COVID-19) has been implicated in a wide spectrum of cardiac manifestations following the acute phase of the disease. OBJECTIVES: To assess the range of cardiac sequelae after COVID-19 recovery. DATA SOURCES: PubMed, Embase, Scopus (inception through 17 February 2021), and Google scholar (2019 through 17 February 2021). STUDY ELIGIBILITY CRITERIA: Prospective and retrospective studies, case reports and case series. PARTICIPANTS: Adult patients assessed for cardiac manifestations after COVID-19 recovery. EXPOSURE: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection diagnosed by polymerase chain reaction (PCR). METHODS: Systematic review. RESULTS: Thirty-five studies (fifteen prospective cohort, seven case reports, five cross-sectional, four case series, three retrospective cohort and one ambidirectional cohort) evaluating cardiac sequelae in 52609 patients were included. Twenty-nine studies utilized objective cardiac assessments, mostly cardiac magnetic resonance imaging (CMR) in sixteen studies, echocardiography in fifteen, electrocardiography (ECG) in sixteen and cardiac biomarkers in eighteen. Most studies had a fair risk of bias. The median time from diagnosis/recovery to cardiac assessment was 48 days (1-180). Common short-term cardiac abnormalities (<3 months) included increased T1 (proportion: 30%), T2 (16%), pericardial effusion (15%) and late gadolinium enhancement (LGE, 11%) on CMR, with symptoms such as chest pain (25%) and dyspnea (36%). In the medium term (3-6 months), common changes included reduced left ventricular global longitudinal strain (30%) and LGE (10%) on CMR, diastolic dysfunction (40%) on echocardiography and elevated NT-proBNP (18%). In addition, COVID-19 survivors had higher risk (RR = 3; 95% CI: 2.7-3.2) of developing heart failure, arrythmias and myocardial infarction. CONCLUSIONS: COVID-19 appears to be associated with persistent/de novo cardiac injury after recovery, particularly subclinical myocardial injury in the earlier phase and diastolic dysfunction later. Larger well-designed and controlled studies with baseline assessments are needed to better measure the extent of cardiac injury and its clinical impact.