Rising cases of silent heart attacks linked to long Covid? WION decodes

Silent heart attack cases have seen a significant rise in India, and some other nations as well, but it remains unclear what is the exact reason behind this alarming trend. WION reached out to doctors and experts to know whether or not silent heart attack cases are linked to the lasting effects of coronavirus (COVID-19) and what should be the preventive measures. 

Dr Prashant Nair, Consultant, Cardiology at Kokilaben Dhirubhai Ambani Hospital Mumbai, told WION, "Silent heart attacks essentially mean that the patient has no symptoms. That means it is incidentally detected on the electrocardiogram or the 2d echocardiography. If you ask the patient if there is any history of chest pain, or breathlessness, or giddiness the patient would emphatically deny it." 

Silent heart attack basically "means that all the classical features that bring a patient to the hospital with a heart attack are not present in this subset," Dr Nair said. 

Silent heart attack and its possible link to long Covid

In December 2023, data from India's National Crime Records Bureau (NCRB) revealed a significant 12.5 per cent rise in heart attack cases in 2022 alone. The NCRB's data on "Accidental Deaths and Suicides in India" stated that 32,457 individuals lost their lives because of heart attacks in 2022, which is a notable rise from the 28,413 deaths recorded in 2021. 

The data suggests that the deaths could have been caused by long Covid, because if heart attacks were caused immediately by the virus, then cases would have risen in 2021 itself as more coronavirus cases were reported in that year as compared to 2022 and 2023. 

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Dr Varun Bansal, Consultant, Cardiology and Cardio Thoracic surgery at Apollo Indraprastha Hospital, New Delhi, told WION: "The prevalence of silent heart attacks is escalating, affecting individuals across diverse age groups and genders." 

"A recent alarming study conducted in Philadelphia has underscored an extremely concerning correlation that has developed between the rising incidence of silent heart attacks post-Covid pandemic and the diverse effects left by the virus," Dr Bansal added. 

"The surge in sudden cardiac deaths is multifactorial, with lifestyle changes playing a pivotal role. A shift towards sedentary activities, insufficient emphasis on cardiac workouts, and an increasing focus on muscle-building activities contribute to the rising incidence," Dr Bansal said. 

Silent heart attacks across various age groups and genders 

Lockdown, social distancing, vaccination programmes, and other measures helped India to curb the spread of the virus and mitigate the disease. But the struggle with long Covid still continues, with even silent symptoms. 

A report published by Statista revealed that a majority of Covid cases in India affected people between ages 31 and 40 years as of October 18, 2021, since the pandemic's onset. Of these, the highest share of deaths during the measured period was observed in people under the age of 50 years. Young people from the age group 21 to 30 years were also massively impacted. 

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Dr Abhijeet Palshikar, Director – Cardiology, Sahyadri Super Speciality Hospital, Deccan Gymkhana, Pune, told WION that the increasing prevalence of silent heart attacks across various age groups and genders is a concerning trend. 

Dr Palshikar also said that it's important to "debunk the misconception that heart disease exclusively affects particular demographics by acknowledging that these silent heart attacks can occur in people of any age or gender". 

"It's critical to take into account the possibility that the COVID-19 pandemic and the rise in silent heart attacks are related, given how the environment has changed as a result of the pandemic. Stress, alterations in lifestyle, and the virus's possible effects on cardiovascular health are all possible contributory variables that should be carefully examined and dealt with," Dr Palshikar added. 

How Covid can cause silent heart attacks? 

Dr Brajesh Kumar Mishra, Intervention Cardiologist and Cardiac Electrophysiologist at Manipal Hospital, Gurugram, explained that long Covid can cause silent heart attacks by several mechanisms, which are:

1) Direct invasion of the arterial wall by a virus causing inflammation and blockage. 
2) Cholesterol removal from blood vessels is done by special blood cells known as macrophages which take lipid cholesterol and become foam cells they are more susceptible to infections and inflammation by Covid virus. 
3) Infection triggering severe inflammation by activation of inflammatory markers CRP and d Dimer leads to activation of clot formation mechanisms. 
4) Inflammatory state leads to inflammation of blockages also leading to heart attack. 

Dr Mishra told WION: "As Covid has problems related to respiratory distress or breathlessness the cardiac events can be hidden in respiratory symptoms. Drugs taken for Covid and inflammatory states make the body more predisposed to heart rhythm disturbances and even stress can lead to poor pump function known as broken heart syndrome. Therefore virus itself or activated clot formation pathway or inflammation increases the risk of heart attack and cardiac arrest in Covid patients." 

Dr Bharat Kukreti, Director and Unit Head- Cardiology, Paras Health, Gurugram, told WION: "Experts have long noted that those infected with the COVID-19 coronavirus, particularly those with pre-existing heart problems, have an elevated risk of heart attacks or strokes for up to a year following the infection. Post-Covid, there is a rise in these incidents due to direct damage to heart cells, causing inflammation and scarring, weakening the heart, and elevating the risk of irregular heartbeats and heart attacks. 

Dr Kukreti explained that this happens when the heart pumps extra blood throughout the body in an effort to fight the infection, further adding that the virus can cause a systemic inflammatory response that damages blood vessels and raises the risk of blood clots, which can impede blood flow and result in heart attacks. 

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Dr Devashish Desai, Consultant of Infectious Diseases at Ruby Hall Clinic, Pune, told WION also weighed in on Covid's direct or indirect link to silent heart attack cases. Dr Desai told WION, "The link between long COVID-19 and an increased risk of cardiovascular events, including heart attacks, is an area of active research and discussion among medical professionals. During the COVID-19 pandemic, there were observations of higher rates of blood clot formation, which could lead to heart attacks, strokes, and other thrombotic events, particularly in patients with hypoxia." 

"It's plausible that the effects of Covid, including inflammation and endothelial dysfunction, could contribute to an increased risk of cardiovascular events both during acute infection and in the long-term, as seen in cases of long Covid. Long Covid refers to persistent symptoms that linger beyond the acute phase of the illness, and it's increasingly recognised as a significant health concern," he further stated. 

Diabetes, Covid vaccine: Are they causing cardiovascular complications? 

Dr Prashant Nair said that the incidence of silent heart attacks is seen more in diabetic patients as they have a higher chance of involvement of the nerves, which are the reasons for causing the pain. "So, long-standing diabetics may not have typical pain or breathlessness, and they may have a silent heart attack. It is also true that silent heart attacks are possible in elderly patients. Because the symptoms are very vague. And they may not have a classical presentation, which you expect in a younger patient," Dr Nair added. 

"The presence of Covid in the past, and the role of vaccination in causing heart attacks is a proven fact for the disease and the treatment. Which means, both have a higher chance of causing heart attacks," Dr Nair said while commenting on the possible impact of vaccination. However, he also explained that "there are no studies that say that silent heart attacks are more common with Covid patients in the past or related to the vaccination". Hence, in-depth studies and research are needed to provide concrete evidence. 

Dr Devashish Desai also mentioned long Covid and silent heart attacks, but he clarified that "while there are observations and hypotheses linking long Covid to cardiovascular complications, more research is needed to fully understand the extent of this relationship, the underlying mechanisms, and appropriate preventive and management strategies". 

Dr Kukreti suggested that the risk of heart attacks is further increased by smoking, obesity, diabetes, high blood pressure, age, and underlying heart problems. He advocated adopting a healthy lifestyle, managing underlying risk factors, and seeking prompt medical attention for symptoms to reduce the likelihood of heart attacks post-Covid. 

Here's what experts are suggesting 

Dr Prashant Nair (Kokilaben Dhirubhai Ambani Hospital Mumbai) 
"I believe that many patients had heart attacks during Covid times, but they were not silent heart attacks. They were probably symptoms which were getting masked because of cough and breathlessness. And obviously, the fact that access to medical hospitals and medical care was also very difficult. So many patients probably continued with care at home without knowing that they had a hard problem." 

Dr Abhijeet Palshikar (Sahyadri Super Speciality Hospital, Deccan Gymkhana, Pune) 
"Medical professionals must stress the value of routine cardiovascular examinations and risk assessments for all people, regardless of age or gender. Addressing this rising trend of silent heart attacks requires a multidisciplinary approach, including public health campaigns specifically for heart diseases also, patient education, and ongoing research to better understand and mitigate the factors contributing to this concerning phenomenon." 

Dr Varun Bansal (Apollo Indraprastha Hospital) 
"Given the vital impact cardiovascular health has on overall well-being, it is extremely imperative that greater public health policy attention be focused towards addressing these interconnected physiological and lifestyle-based risk factors systematically and invested in mitigating the expanding acute—as well as lasting—impact silent myocardial infarctions may exert upon community health in the near future." 

Dr Devashish Desai (Ruby Hall Clinic)
"If there's a connection between long Covid and an increased risk of cardiovascular events, including silent heart attacks, it underscores the importance of monitoring and managing the long-term health implications of Covid survivors."