New reports on early symptoms, cardiac complications of COVID-19

On March 22, the American Academy of Otolaryngology—Head and Neck Surgery proposed that, based on accumulating anecdotal evidence, anosmia, hyposmia, and dysgeusia should be considered symptoms of COVID-19 and warrant serious consideration for self-isolation and testing. One example of the evidence was a study of 59 hospitalized Italian patients, 20 of whom reported a taste or olfactory disorder, according to a research letter published by Clinical Infectious Diseases on March 26.

Emerging data are showing cardiac injury to be common among patients with COVID-19 and associated with worse outcomes. In one study of 416 Chinese inpatients, published by JAMA Cardiology on March 25, cardiac injury occurred in 19.7%; inpatient mortality was 51.2% in the patients with injury compared to 4.5% in those without. Cardiac injury was more common among patients with hypertension or coronary artery disease at baseline, leading the authors to “hypothesize that an intense inflammatory response superimposed on preexisting cardiovascular disease may precipitate cardiac injury observed in patients with COVID-19 infections.”

A second Chinese study, published by JAMA Cardiology on March 27, looked at 187 hospitalized patients, 35.3% of them with underlying cardiovascular disease (CVD). Overall, 27.8% had myocardial injury as indicated by elevated troponin T levels. Inpatient mortality was 7.62% in patients without underlying CVD or troponin elevation, 13.33% in those with underlying CVD and normal troponin, 37.50% in those without underlying CVD but with elevated troponin, and 69.44% in those with both CVD and elevated troponin. The authors noted that their data didn't show any difference in mortality associated with angiotensin-converting enzyme inhibitors or angiotensin-receptor blockers, suggesting that these drugs may not need to be discontinued in patients with COVID-19.

“Whether the data linking myocardial injury and high mortality risk in patients with COVID-19 from the 2 Chinese cohorts are generalizable to other countries, including the US, is yet to be determined. But the wake-up call has been delivered. We have a similar profile of elderly patients with cardiovascular disease in the US and other Western countries in which the toll of COVID-19 could be daunting,” concluded an accompanying editorial. JAMA Cardiology also published a case report and a review of potential effects of the virus on the cardiovascular system on March 27.

Possible treatments for COVID-19 were reviewed in an article published by Open Forum Infectious Diseases on March 23. The authors summarized early and emerging treatment options on behalf of the Society of Infectious Diseases Pharmacists, based on data released on or before March 19. They found remdesivir to be a promising agent based on emerging and in vitro evidence and suggested hospitals explore clinical trial enrollment or compassionate use to get it for moderate-to-severe COVID-19 patients. Data from China and France are also encouraging on chloroquine or hydroxychloroquine, the reviewers said, recommending that clinicians follow research in this area, and if they choose to use hydroxychloroquine, be cautious in dosing. The reviewers found it difficult to assess whether lopinavir/ritonavir has a role either as monotherapy or in combination based on current evidence. Nitazoxanide has shown encouraging effectiveness in vitro, but more data are needed to determine its role in management, the review said. Tocilizumab and corticosteroids were reviewed as possible adjunctive therapies, without definitive conclusions on their value. The review also listed treatments that have been considered for COVID-19 but carry greater risk than benefit and a number that are being studied but currently have too little evidence to determine whether they may be useful.