Cardiovascular dysfunction has emerged as one of the myriad effects of SARS-CoV-2 infection, but SARS-CoV-2 is not unique among viral pathogens in its capacity to damage the cardiovascular system. Monday afternoon’s session, “Acute and Chronic Cardiovascular Disease Complications in Patients with Viral Infections,” will highlight some of the cardiovascular morbidities suffered by patients with viral infections. It also will explore not only laboratory aspects and emerging biomarkers, but radiological findings and the underlying mechanisms of both damage and the subsequent release of select biomarkers.

Alan Wu, PhD, will moderate the session. Like many laboratorians, Wu found himself in the midst of an “all hands on deck” experience at University of California at San Francisco when the COVID-19 pandemic began, but with the finding that cardiac troponin levels increased in severe COVID-19 cases, SARS-CoV-2 became a natural fit with Wu’s interests. Wu will present on the pathophysiological mechanisms of inflammatory cardiomyopathy caused by viral infections. An interesting feature of SARS-CoV-2 is that the cardiovascular damage more closely resembles that due to sepsis. Indeed, critical care physicians have suggested that patients with a severe COVID-19 infection be considered as having “viral sepsis.” Release of cardiac troponin is, likewise, increased as in bacterial sepsis, though in both instances, the clinical significance is unclear. Wu will postulate a role for extracellular vesicles released by cardiomyocytes in the release of cardiac troponin in viral infections, similar to what is proposed to occur in reversible cardiomyocyte injury.

Priscilla Hsue, MD, also at the University of California at San Francisco and the chief of cardiology at Zuckerberg San Francisco General Hospital and Trauma Center, is an internationally recognized expert on cardiovascular disease in the setting of HIV. Hsue’s previous work demonstrated that sudden cardiac death is more than 4.5 times as high among HIV-positive individuals. She describes myocardial fibrosis and decreased cardiac function occurring with greater incidence among HIV-positive individuals, but points out that many mechanisms underlying these changes remain elusive. Likewise, SARS-CoV-2 demonstrates cardiovascular damage, though it’s generally less severe than in HIV. Hsue will present on the unique clinical and radiographic findings in individuals with cardiovascular damage due to viral infections, including SARS-CoV-2 and HIV.

Jieli Shirley Li, MD, PhD, of The Ohio State University Wexner Medical Center, will close the session with a discussion of biomarkers of viral myocarditis. These will range from the familiar, such as cardiac troponin, to biomarkers less associated with cardiovascular illness, as well as novel biomarkers. “Highly elevated cardiac markers and enzymes may help to rule in acute cases, but absence of them does not exclude myocarditis,” notes Li. That’s where novel biomarkers may prove useful.

Some of the novel biomarkers Li will discuss are soluble ST2, a member of the interleukin-1 receptor family, and microRNAs. She will also discuss the Diagnosis of Acute Myocarditis in Emergency (DAME) score, which calculates a risk score using a combination of laboratory measurements, clinical signs and symptoms, and echocardiographic ultrasound. Additionally, she’ll discuss the use of machine learning for diagnosis and prognosis of myocarditis.

Attendees at this session should expect to leave the session with a greater understanding of cardiovascular disease and complications resulting from viral infections, as well as an appreciation for the prevailing theories concerning the underlying mechanism of myocardial damage. Novel biomarkers are always on the horizon, and attendees should likewise leave with an appreciation for some promising candidates for the detection of myocarditis.