Description and Proposed Management of the Acute COVID-19 Cardiovascular Syndrome

Circulation. 2020 Jun 9;141(23):1903-1914. doi: 10.1161/CIRCULATIONAHA.120.047349. Epub 2020 Apr 16.


Coronavirus disease 2019 (COVID-19) is a rapidly expanding global pandemic caused by severe acute respiratory syndrome coronavirus 2, resulting in significant morbidity and mortality. A substantial minority of patients hospitalized develop an acute COVID-19 cardiovascular syndrome, which can manifest with a variety of clinical presentations but often presents as an acute cardiac injury with cardiomyopathy, ventricular arrhythmias, and hemodynamic instability in the absence of obstructive coronary artery disease. The cause of this injury is uncertain but is suspected to be related to myocarditis, microvascular injury, systemic cytokine-mediated injury, or stress-related cardiomyopathy. Although histologically unproven, severe acute respiratory syndrome coronavirus 2 has the potential to directly replicate within cardiomyocytes and pericytes, leading to viral myocarditis. Systemically elevated cytokines are also known to be cardiotoxic and have the potential to result in profound myocardial injury. Prior experience with severe acute respiratory syndrome coronavirus 1 has helped expedite the evaluation of several promising therapies, including antiviral agents, interleukin-6 inhibitors, and convalescent serum. Management of acute COVID-19 cardiovascular syndrome should involve a multidisciplinary team including intensive care specialists, infectious disease specialists, and cardiologists. Priorities for managing acute COVID-19 cardiovascular syndrome include balancing the goals of minimizing healthcare staff exposure for testing that will not change clinical management with early recognition of the syndrome at a time point at which intervention may be most effective. This article aims to review the best available data on acute COVID-19 cardiovascular syndrome epidemiology, pathogenesis, diagnosis, and treatment. From these data, we propose a surveillance, diagnostic, and management strategy that balances potential patient risks and healthcare staff exposure with improvement in meaningful clinical outcomes.

Keywords: COVID-19; SARS-CoV-2; cardiomyopathies; heart failure; myocarditis.

Publication types

  • Review

MeSH terms

  • Angiotensin-Converting Enzyme 2
  • Antiviral Agents / therapeutic use
  • Arrhythmias, Cardiac / etiology
  • Arrhythmias, Cardiac / physiopathology
  • Arrhythmias, Cardiac / therapy
  • Biomarkers
  • COVID-19
  • COVID-19 Serotherapy
  • Cardiovascular Diseases / diagnosis
  • Cardiovascular Diseases / etiology*
  • Cardiovascular Diseases / physiopathology
  • Cardiovascular Diseases / therapy
  • Coronavirus Infections / complications*
  • Coronavirus Infections / drug therapy
  • Coronavirus Infections / therapy
  • Cytokine Release Syndrome / etiology
  • Cytokine Release Syndrome / physiopathology
  • Cytokine Release Syndrome / therapy
  • Cytokines / metabolism
  • Disease Management
  • Hemodynamics
  • Humans
  • Immunization, Passive
  • Immunoglobulins, Intravenous / therapeutic use
  • Infectious Disease Transmission, Patient-to-Professional / prevention & control
  • Interleukin-6 / antagonists & inhibitors
  • Molecular Targeted Therapy
  • Myocarditis / diagnosis
  • Myocarditis / etiology
  • Myocarditis / physiopathology
  • Myocarditis / therapy
  • Organ Specificity
  • Pandemics
  • Peptidyl-Dipeptidase A / physiology
  • Pneumonia, Viral / complications*
  • Pneumonia, Viral / drug therapy
  • Receptors, Virus / physiology
  • Risk Factors
  • Serine Endopeptidases / physiology
  • Severe Acute Respiratory Syndrome / therapy
  • Spike Glycoprotein, Coronavirus / physiology
  • Viral Tropism


  • Antiviral Agents
  • Biomarkers
  • Cytokines
  • IL6 protein, human
  • Immunoglobulins, Intravenous
  • Interleukin-6
  • Receptors, Virus
  • Spike Glycoprotein, Coronavirus
  • spike protein, SARS-CoV-2
  • Peptidyl-Dipeptidase A
  • ACE2 protein, human
  • Angiotensin-Converting Enzyme 2
  • Serine Endopeptidases
  • TMPRSS2 protein, human