A 70% drop in the number of individuals who presented with heart attacks was witnessed in the initial wave of COVID-19, says cardiologist Melanie Zammit Burg, attributing the decline mainly to people’s fear of catching the virus from hospitals.

They preferred to “bear the pain” and wait it out at home, to the detriment of their health and the possibility of long-term complications of a heart attack that is not treated with immediate intervention, Zammit Burg said.

“With cardiac patients being among the most vulnerable and most likely to suffer the worst effects of the virus, cardiac services, nevertheless, continued round the clock during the pandemic,” she said.

The virus has been described as “mild” in Malta by the prime minister but the cardiologist maintains this does not guarantee a quick and easy recovery.

“Being a completely novel virus that only came to clinical recognition eight months ago, we lack the experience to say what its long-term effects will be.

“However, medical research has been very fast in studying its implications and we are starting to recognise effects that go beyond the acute infection.”

Understanding 'long COVID'

One of these is post-acute COVID-19 – termed “long COVID”.

It is now understood that at least 10 per cent of people infected will experience a prolonged illness that may last for months after the initial infection, Zammit Burg explained.

Symptoms include ongoing fatigue, difficulty breathing, sweats, headaches, fevers, muscle aches, chest pains, neurocognitive difficulties and depression. 

“And this is something we have seen locally,” Zammit Burg points out. 

Long COVID may occur irrespective of the degree of severity of the illness – in a study from Rome, a good proportion of people experiencing it had very mild symptoms, if any.

“Although we are still continuously learning about it, we now have a reasonably good understanding of the acute and early effects of COVID-19 on the heart,” says Zammit Burg.

Possible long-term complications are being seen in patients who received cardiac MRI imaging post COVID-19, according to studies. Locally, however, patients have not yet started to be routinely followed up with MRIs because the numbers have, luckily, been too few.

Quoting the Journal of the American Medical Association, Zammit Burg said 78 per cent of recovered patients had evidence of cardiac involvement irrespective of whether they had pre-existing conditions and the severity of the infection.

Many of these patients were healthy, young individuals, who got COVID-19 during skiing trips.

These may lead to heart failure and arrhythmias in the future and require follow-up. “So even if you are young and healthy, COVID-19 is not an infection you want to get,” Zammit Burg warns.

“We also know that people with cardiovascular disease, such as those who have had a prior heart attack or stroke, are at a greater risk of developing a more severe form of the infection.”

They are also at increased risk of dying of COVID-19 – 40 per cent of patients admitted to hospitals for this have pre-existing cardiovascular disease.

While the overall risk of dying from COVID-19 in the population is 2.3 per cent, if you have heart disease, the risk increases to 10.5 per cent, which is why healthcare systems and public health authorities have been rallying so much for protecting these so-called vulnerable individuals, Zammit Burg says.

“Thanks to robust public health interventions during the first wave in Malta, and perhaps a bit of luck, our number of hospitalised cases and death rates were too low to draw strong conclusions, but we have looked after hospitalised patients who have had elevated levels of an indirect marker of heart damage known as Troponin,” the cardiologist explained.

Increased risks

This cardiac biomarker is released in the blood when the heart muscle is injured, typically during a heart attack, but also when the heart is inflamed, or following a pulmonary embolism. 

High Troponin levels in patients with COVID-19 are, in turn, associated with a higher mortality rate, she said.

This phenomenon, recorded in a study among London patients, was more common in people with pre-existing heart disease but also observed in young, previously healthy, individuals.

“Maltese patients are no different from our neighbouring countries,” Zammit Burg emphasised.

Possible long-term consequences can be deducted from other coronavirus pneumonia pandemics, with survivors of these infections having increased risk of cardiovascular disease 10 years down the line. 

“We will have to wait and see if the same will hold true with COVID-19,” Zammit Burg said.

Tips for cardiovascular disease sufferers

The virus cannot infect people it cannot reach, so prevention really is better than cure, according to cardiologist Melanie Zammit Burg.

Public Health recommendations to keep a safe distance, avoid crowds, proper use of face masks, washing hands frequently with soap and water or alcohol hand rubs, are key measures to keep safe until the crisis is behind us.

Maintaining good cardiovascular health, with regular sleep, good nutrition, physical activity, even in the confines of social distancing, and finding coping mechanisms to counteract the inevitable anxiety, such as yoga, meditation, prayer, hobbies and keeping in touch with loved ones, is vital, she says.

Zammit Burg appeals to those who have cardiovascular disease to make sure they take medications regularly, ensure they have at least a month’s stock at home and speak to their cardiologist if they have any concerns. 

“Do not miss hospital appointments and do not be afraid to seek healthcare if you need it,” she warned.