The Surprising Increase in Heart Attacks After COVID-19.

The Indian Council of Medical Research is conducting studies to investigate the rising cases of cardiac arrest after COVID-19, particularly among young adults.

To ascertain the facts regarding the apprehension of rising cases of cardiac arrest after COVID-19, Indian Council of Medical Research (ICMR) is conducting following three different studies.

1. “Factors associated with sudden deaths among adults aged 18 – 45 years, India: multicentric matched case control study” conducted at ~ 40 hospitals/research centers. Cases were individuals between the ages of 18 and 45 who died unexpectedly, including sudden cardiac death, and were reported in the study hospitals between the 1st of October 2021 and the 31st of March 2023.

2. “Effect of COVID-19 vaccine on thrombotic events among 18 – 45 years old population in India, 2022: multicentric hospital based matched case control study” conducted at ~ 30 COVID-19 clinical registry hospitals. Conducted based on the  resources collected from the beginning of the SARS-CoV-2 pandemic, and the consequent coronavirus disease 2019 (COVID-19), up to date (6 February 2022).

3. “Establishing the cause in sudden unexplained death in the young”, through virtual and physical autopsy.

The government provides support to states and union territories to address cardiovascular disease through the National Programme for Prevention and Control of Non-Communicable Diseases. Various measures have been taken to improve healthcare infrastructure and make treatment more accessible and affordable, including health insurance coverage, financial assistance for families below the poverty line, and the availability of generic medicines at affordable prices. Additionally, AMRIT Pharmacy stores have been established to provide cardiovascular drugs at discounted prices.

The study found that COVID-19 vaccination did not increase the risk of sudden death, but past COVID-19 hospitalization, family history of sudden death, and certain lifestyle behaviors were positively associated with unexplained sudden deaths. The study collected data on tobacco smoking, alcohol consumption, drug use, physical activity, and COVID-19 vaccination status, and found that receipt of two doses of the COVID-19 vaccine was associated with lower odds of sudden death. The Indian Council of Medical Research also conducted a case-control study suggesting that the vaccine may reduce the risk of such deaths.

Cardiac injury:

Some of the proposed mechanisms for cardiac injury during the acute phase of COVID-19 include direct viral infection of the vascular endothelium and myocardium, invasion of endothelial cells causing endotheliitis, and the cytokine storm triggered by the immune response against SARS-CoV-2.

Additionally, respiratory failure may induce hypoxic injury with an acute imbalance in myocardial oxygen supply without atherothrombosis, and overwhelming cytokine release and excessive Angiotensin II activity may lead to endothelial activation, increased endothelial permeability, vascular inflammation, and inflammation-induced hypercoagulability with intracoronary thrombosis. Other potential mechanisms include atherosclerotic plaque instability and rupture, increased metabolic demand, and reduced cardiac reserve with myocardial dysfunction.

The mechanisms proposed for continuing cardiac injury in the post-acute phase of COVID-19 include long-term functional and structural cardiac damage due to inflammation associated with viral persistence in the heart tissue, immune dysregulation, and the development of autoimmune response to cardiac antigens. The perseverant inflammation may cause tissue damage and myocardial fibrosis leading to decreased ventricular compliance, impaired myocardial perfusion, increased myocardial stiffness, reduced contractility, and potential arrhythmias. These factors contribute to the structural changes and functional abnormalities observed in the post-acute phase of COVID-19.

Patients with COVID-19 related myocarditis should not start any cardiac rehabilitation or exercise program for 3-6 months. However, if the left ventricular ejection fraction (LVEF) is within normal and no arrhythmias are present, a lighter exercise program can be started three months post-infection. If the patient displays a low LVEF, they should be reevaluated six months before any exercise activity decision.

Acute Myocardial Infarction:

Some potential reasons proposed for the observed excess AMI (Acute Myocardial Infarction) mortality during the pandemic include:

Activation or acceleration of pre-existing subclinical coronary artery disease due to SARS-CoV-2 infection, particularly among younger-aged men with clustering of cardiometabolic risk factors.

Psychological stressors associated with the pandemic, which may have played a role in triggering events leading to excess AMI-associated mortality.

Effects of social distancing and stay-at-home mandates, reductions in outpatient visits and rehabilitation services, and deferment of elective procedures, which likely contributed to the overall excess of AMI-associated deaths during the COVID-19 pandemic.

These factors, among others, are suggested as potential contributors to the increased AMI-associated mortality observed during the pandemic.

The study found that younger adults, particularly those in the 25-to-44-year age group, experienced the greatest relative increases in excess AMI-associated mortality compared to predictions. Additionally, the relative increase was more pronounced in males than females, especially during the fourth epoch marked by the Omicron surge. This indicates that younger males were one of the subgroups experiencing the greatest relative increases in excess AMI-associated mortality during the pandemic.

Myocarditis:

There was a study conducted which aimed to synthesize evidence on the incidence rates and risk factors for myocarditis and pericarditis after using mRNA vaccination against COVID-19. The study included 46 studies, including 14 on incidence, seven on risk factors, 11 on characteristics and short term course, three on longer term outcomes, and 21 on mechanisms. The results showed that the highest incidence of myocarditis after mRNA vaccines was in male adolescents and young adults aged 12-17 years.

The incidence of myocarditis after a third dose had very low certainty evidence. For individuals aged 18-29 years, the incidence of myocarditis might be higher after vaccination with mRNA-1273 compared with Pfizer. The study also found that most myocarditis cases involved men of a median 20-30 years of age and with symptom onset two to four days after a second dose. The study concluded that adolescent and young adult men are at the highest risk of myocarditis after mRNA vaccination.

The Department of Health & Family Welfare, Government of India, however, provides technical and financial support to the States/UTs under the National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases and Stroke (NPCDCS), as part of National Health Mission (NHM), based on the proposals received from the States/UTs and subject to the resource envelope.

The programme focusses on strengthening infrastructure, human resource development, health promotion & awareness generation for prevention, early diagnosis, management and referral to an appropriate level of healthcare facility for treatment of the Non-Communicable Diseases (NCDs).

A population-driven initiative to prevent, control and screen for common NCDs is being implemented under the Comprehensive primary health care (CPHC) scheme. This includes promoting wellness activities and creating targeted communication at community level. Patients with cardiovascular disease are being treated in various healthcare facilities, such as district hospitals and medical colleges, as well as in central institutes, government hospitals, and private sector hospitals. Treatment in public hospitals is free or heavily subsidised for poor and disadvantaged patients. The National Health Mission (NHM) is also providing medical care to patients under the PMJAY scheme. Additionally, there is an increased focus on cardiovascular diseases under the new AIIMS and many upgraded institutions under the PMSSY.

 

Links

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8880092/

https://sansad.in/getFile/loksabhaquestions/annex/1712/AS30.pdf?source=pqals

https://journals.lww.com/ijmr/fulltext/2023/10000/factors_associated_with_unexplained_sudden_deaths.6.aspx

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10063539/

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9839603/

https://www.thelancet.com/journals/eclinm/article/PIIS2589-5370(22)00349-2/fulltext

https://www.bmj.com/content/378/bmj-2021-069445

https://sansad.in/getFile/loksabhaquestions/annex/1711/AU1387.pdf?source=pqals

https://www.healthdata.org/sites/default/files/files/policy_report/2017/India_Health_of_the_Nation%27s_States_Report_2017.pdf

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