2023;3(1) – ABC CARDIOL

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Review Article

Uncompacted Myocardium: A Disease or a Phenotype?

Vinícius Machado Correia et al. Vagner Madrini Junior Félix José Alvarez Ramires

Introduction

Non-compacted myocardium (NCM) remains controversial between those who consider it a genetic cardiomyopathy and those who believe that excessive trabeculation is a characteristic morphological condition shared by distinct pathological processes and, therefore, not a single disease.

The hallmark of this phenotype is the presence of prominent trabeculae in the left ventricle (LV) and deep intertrabecular recesses, continuous with the LV cavity and separated from the epicardial coronary arteries.^, Such abnormalities are identified through imaging exams and may affect the LV, the right ventricle (RV), or both, and do not by themselves define cardiomyopathy.

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Review Article

Stress Cardiomyopathy (Takotsubo)

Marcelo Westerlund Montera

Introduction

Takotsubo Cardiomyopathy (CT), also known as stress-induced cardiomyopathy, is a reversible syndrome that usually presents as an acute coronary syndrome, especially in postmenopausal women. The pathophysiology involves multiple factors, including coronary vasospasm, microcirculation dysfunction, catecholaminergic aggression, and sympathetic hyperactivity. The diagnosis of the classic presentation is the presence of a segmental alteration in the form of ballooning or dyskinesia in the antero-septo-apical region of the left ventricle, associated with hyperdynamia of the basal segments, in the absence of obstructive coronary disease that justifies this alteration in contraction. Initially, it was believed that CT was a self-limiting condition with a good prognosis; however, it is currently recognized as a pathology with a high rate of complications and high morbidity and mortality in the short and long term. Even though the first description was made more than 30 years ago, in 1990, by Sato, the etiology and pathophysiology are still not fully defined, and we still do not have an international guideline for standardizing diagnosis and treatment.

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Viewpoint – Brazilian Guideline for Myocarditis

Marcelo Westerlund Montera et al. Daniella Motta da Costa Dan Fabiana G. Marcondes-Braga

Diagnosis

The criterion for the diagnostic confirmation of myocarditis defined by the 2013 European and Brazilian Myocarditis Guidelines is the identification of myocardial inflammation by endomyocardial biopsy (EMB).^, This diagnostic criterion, used solely without the option of classifying clinical suspicion, does not mirror clinical practice in the real world, where only a minority of patients in specialized centers are referred for diagnostic investigation through EMB with diagnostic confirmation or exclusion, and most have the diagnosis of clinical suspicion of myocarditis. As an innovation, the 2022 Brazilian Guideline introduces an organizational chart to establish the degrees of suspected diagnosis of myocarditis, which correspond to clinical practice in the real world, where most patients will have a diagnosis of suspected myocarditis rather than confirmation. This organization chart is based on clinical history, myocardial injury biomarkers, electrocardiogram, echocardiogram, and cardiac magnetic resonance, to establish a diagnostic suspicion of myocarditis (), which will define different approaches regarding follow-up, treatment, and the need for EMB. Patients with low suspicion of myocarditis have a favorable prognosis with a low risk of developing ventricular dysfunction or cardiovascular mortality, and clinical follow-up is indicated without the need for cardioprotective drugs. Cardioprotective drugs and clinical and ventricular function follow-up by echocardiogram and magnetic resonance imaging are indicated for patients with an intermediate degree of suspicion of miocarditis. Patients with high diagnostic suspicion or with intermediate suspicion with worsening clinical or ventricular function have a worse long-term prognosis, with lower survival, being indicated in this group the EMB for the investigation of the inflammatory activity and the etiological agent to evaluate treatment with immunosuppressants and therapy directed towards the identified etiological factor (). With the diagnostic suspicion classification, the new Guideline approaches clinical practice, standardizing the clinical management of most patients with suspected myocarditis and reserving the indication of EMB for those with greater potential for clinical benefit from immunosuppressive therapy.

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Review Article

Arrhythmogenic Left Ventricular Cardiomyopathy – State of Art: From Genotype to Phenotype

Ana Flavia Malheiros Torbey et al. Erivelton Alessandro do Nascimento Nágela Simão Vinhosa Nunes Adriana Bastos Carvalho … Daniel Gama das Neves Raquel Germer Toja Couto Sandra Vitória Thuler Pimentel Eduarda Corrêa Maia Evandro Tinoco Mesquita

Abstract

Arrhythmogenic cardiomyopathy with exclusive or predominant involvement of the left ventricle has been described recently. It has a heterogeneous genetic basis with different clinical phenotypes ranging from ventricular arrhythmias and sudden death (SD), symptoms suggestive of acute myocarditis with chest pain and troponin elevation, symptoms of heart failure, to asymptomatic patients. A high level of suspicion is needed for a correct diagnosis and implementation of a genotype-based therapy, to prevent its most feared complication, SD. This review aims to describe arrhythmogenic left ventricular cardiomyopathy as a genetic heart disease, with initial and/or predominant involvement of the left ventricle and its varied phenotypic expression, providing a basis for clinical reasoning and “red-flags” for the diagnosis, as well as for SD risk stratification.

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Review Article

Genetics in Cardiomyopathies – Genetic Tests Decoded for the Clinical Cardiologist

Arsonval Lamounier Júnior et al. Diane Xavier de Ávila Roberto Barriales-Villa

Abstract

The era of personalized medicine emphasizes the provision of health care guided by the cardiomyopathy phenotypes described, their interpretation based on genotype, and genetic counseling. The identification of high-risk cardiomyopathy subtypes and the diagnosis of rare etiologies with potential therapies cannot be neglected. Genetic sequencing of these patients, in addition to advances in cardiac imaging techniques, has indicated a new perspective for these concepts, and consequently possible new classifications of cardiomyopathies and new clinical practices. The interaction between multidisciplinary teams and cardiology genetic experts is fundamental for a more appropriate management of gene variants, especially variants of uncertain significance that may be relevant in the expression of cardiomyopathies. This article helps cardiologists in the ordering of genetic tests and their indications, provides information about pathogenicity of variants and emphasizes family screening, challenges that may be overcome in daily practice.

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Review Article

Pediatric Cardiomyopathies: Establishing Genotype-Phenotype Relationship as a Determinant in Prognosis and Therapy: A Review of the Literature

Ana Flavia Malheiros Torbey et al. Aurea Lucia Alves de Azevedo Grippa de Souza Estela Azeka Maraisa Fachini Spada

Abstract

Cardiomyopathies constitute a heterogeneous group of diseases with varying etiologies and clinical presentation. Advances in genetic testing have made it possible to establish genotype-phenotype relationships, determine prognosis, and choose specific treatments in the pediatric population. Therefore, the objective of this review is to assist clinical reasoning and underscore the importance of etiological diagnosis in different disease phenotypes.

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Post-COVID-19 Cardiomyopathy in Children and Adults: Fact or Fiction?

Anna Esther Araujo e Silva et al. Ana Flavia Malheiros Torbey Aurea Lucia Alves de Azevedo Grippa de Souza

Since the emergence of the novel coronavirus 2019 disease (COVID-19), cardiovascular impairment and alterations in cardiology laboratory tests suggestive of myocardial injury, even in patients without cardiovascular symptoms, have been observed in hospitalized children and adults.^–

Epidemiological data from China have suggested that cardiac injury may occur in 19% to 28% of hospitalized patients with COVID-19. Several factors seem to contribute to myocardial damage, and potential mechanisms of injury include: hypoxic injury, stress cardiomyopathy, ischemic lesion caused by cardiac microvascular dysfunction, small vessel cardiac vasculitis, endotheliitis, epicardial coronary artery disease, right heart distention (acute cor pulmonale with pulmonary embolism), myocarditis, systemic inflammatory response syndrome (cytokine storm), and others ^, ().

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Brazilian Scientific Production about Cardiomyopathies: A Review from 2010 to 2022

Even Edilce Mol et al. Sarah Fagundes Grobe Luis Eduardo Paim Rohde Lídia Ana Zytynski Moura

By definition, myocardiopathies or cardiomyopathies (CM) are heart muscle diseases that cause structural and functional myocardial abnormalities in the absence of coronary artery disease, hypertension, valvular disease, and congenital heart disease.^,

CM constitute a very heterogeneous group of heart diseases and are one of the leading causes of death either from end-stage heart failure or sudden death due to arrythmias. According to the phenotype, CM may be classified into hypertrophic cardiomyopathy, dilated cardiomyopathy, restrictive cardiomyopathy, arrhythmogenic right ventricular cardiomyopathy, and left ventricular noncompaction, where there may overlap of phenotypes. Each phenotype is then subclassified into: genetic origin (familial), non-genetic (non-familial), and mixed, with the genetic form accounting for most of the cases. According to the statement of American College of Medical Genetics and Genomics, of the 59 genes mentioned in the document, 30 (51%) had cardiovascular phenotypes, and 16 (27%) included CM phenotypes. Non-genetic CM may be caused by infections, autoimmune diseases, and endogenous or exogenous myocardial toxicity, whereas genetic CM may be caused by a variety of known mutations and others under study.

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Surgical Treatment of Cardiomyopathy

Lucas F. Cardoso et al. Samuel P. Steffen Fabio A. Gaiotto

Ischemic Cardiomyopathy

Ischemic heart disease is the most common cause, and at the same time, it is the main isolated risk factor that favors the increased incidence of heart failure in the world.

Several improvements incorporated in coronary artery bypass graft surgery have made the procedure safer and more effective, so patients who were previously candidates for heart transplants are now frequently revascularized. Hausmann et al. showed that, with the more comprehensive indication of myocardial revascularization in this scenario, patients with advanced heart failure due to ischemic cardiomyopathy now represent 29.3% of recipients who are candidates for transplantation in the studied center, in comparison with data from the same period by the International Society of Heart and Lung Transplantation, which indicated that 47.2% of recipients had an ischemic etiology.

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Clinical Reasoning and Classification of Cardiomyopathies

Vagner Madrini Junior et al. Evandro Tinoco Mesquita Diane Xavier de Avila Fabio Fernandes

Definition

Cardiomyopathies (CMPs) are a group of diseases with multiple etiologies and heterogeneous phenotypes, ranging from microscopic changes in cardiomyocytes in asymptomatic patients to cases of fulminant heart failure with fluid retention, and perfusion and heart rhythm changes. A CMP was initially defined as a heart muscle disease caused by genetic defects, myocyte injury or myocardial infiltration, and characterized by structural and functional abnormalities in the absence of congenital disease, valvular disease or hypertension. The initial approach of patients with CMP consists of clinical evaluation and complementary imaging techniques and genetic testing, in search of diagnostic evidence and the need for specific tests ().^,

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Genetic Counseling and Pedigree in Cardiomyopathies – the Role of the Clinical Geneticist

Diane Xavier de Ávila et al. Frank Nunes Raquel Germer Ana Flávia Malheiros Torbey

Introduction

Twenty years ago, the Human Genome Project made history by announcing the sequencing of 92% of the human genome through the development of modern genetic sequencing techniques. In 2022, the complete sequencing of human DNA was announced. This knowledge made it possible to better understand how genetics influences the functioning of the human body and, at the same time, facilitated the identification of genetic variants that can cause diseases.

In the field of cardiology, genetic study assists the assessment of aortopathy, familial hypercholesterolemia, channelopathies, and especially cardiomyopathies.

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Review Article

Diagnosis and Treatment of Hypertrophic Cardiomyopathy

Fernando Saraiva et al. Fabio Fernandes Minna Moreira Dias Romano Juliano Novaes Cardoso … Marília Taily Soliani Mariani Mendes Madisson Bernardo André Schmidt Marcus Vinicius Simões

Abstract

The concept of hypertrophic cardiomyopathy has undergone profound changes with the advent of cardiogenomics and the increase in knowledge about the sarcomeric structure and the mutations that lead to cardiomyocyte hypertrophy. In this review article, we address the state of the art in terms of diagnosis, contemplating the genetic heart diseases responsible for differential diagnoses of hypertrophic cardiomyopathy, known as phenocopies, which are a major challenge in clinical practice. We also discuss the current evidence that guides treatment.

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Advances in the Diagnosis and Treatment of Cardiac Amyloidosis

Marcus Vinicius Simões et al. Diane Xavier de Ávila Pedro Manoel Marques Garibaldi Evandro Tinoco Mesquita

Introduction

In recent decades, significant advances have led to a complete reformulation of clinical and epidemiological concepts about cardiac transthyretin (ATTR) amyloidosis, summarized in .

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Special Article

Cardiomyopathies: Yesterday, Today, and Tomorrow

Charles Mady et al. Diane Xavier de Ávila Vagner Madrini Junior Evandro Tinoco Mesquita

The interest in myocardial damage is very old, but only in recent decades has there been a reasonable advance in greater knowledge thereof. Ancient peoples were limited to rudimentary observations on the morphology and physiology of the circulatory system, but with special interest directed to the heart. Texts in cuneiform scripts from Sumer, considered the first civilization in human history; others from the Library of Ashurbanipal, with inscriptions on clay tiles, discovered intact under the sands at Nineveh; Egyptian hieroglyphs in stone and ink; and writings by the Mayans, the only people in the Americas to leave reports in their alphabet as well as books, of which we have only copies in some cases (the Spanish invaders took it upon themselves to destroy and burn many originals) all demonstrate an ancient interest in human anatomy and the heart. With the limitations of their times, they demonstrated curiosity about the constitution of the human body, reaching academic-level descriptions by Leonardo da Vinci’s time. Recent developments have brought us new knowledge about the etiopathogenesis and pathophysiology of the diseases that affect the heart, but they are not sufficient to generate greater therapeutic advances. There are reasons for this.

As these diseases are predominantly clinically treated, cardiology has spent the past few decades committed to understanding and disseminating themes considered more relevant in surgical areas, such as coronary, congenital, and valve diseases, which were and are subjected to highly developed treatments in the recent past, with more immediate results. The drug and equipment industries have understood the size of the doors open to their interests, actively participating in research associated with academic institutions. There is no doubt that the evolution in these fields has been enormous, with remarkable material interests, massively concentrating research, symposiums, congresses, and publications on these themes. Spaces for cardiomyopathies were very limited, due to almost total lack of interest, and therapy in these fields was limited to digitalis and diuretics, indicated for heart failure, and not for underlying diseases. It was a world apart within cardiology. It took a long time for new drugs to be studied and released on the market, but only for the treatment of dysfunction as a syndrome. There was a long delay in creating laboratories to promote understanding of the etiological factors of myocardial aggression, in an attempt to understand, reduce, or eliminate the lethality of these diseases, many of which are still little known, and to attempt to develop specific treatments for each cause. Unfortunately, we are still a long way from this goal. As an example, I cite the old and current Chagas cardiomyopathy. We treat the consequences, heart failure, thromboembolisms, and arrhythmias, but to date we do not have any truly effective specific treatment, in a society that contains a significant part of the infected population. Even prevention, which is inexpensive, given that it simply uses insecticides, is carried out on a modest scale. It has become conventional to use the terminology “disease of the poor” to justify this lack of interest. Nonetheless, this delay generates a huge social cost in the health area.

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Editorial

The Era of Personalized Medicine in Cardiomyopathies

Diane Xavier de Avila et al. Evandro Tinoco Mesquita

Learning about cardiomyopathies has become more in-depth in recent years. Thus, several views of specialists from Brazil are present in this edition of ABC Heart Failure & Cardiomyopathy, of the ABC Family of Arquivos Brasileiros de Cardiologia (ABC Cardiol), from the most common etiologies to the rarest and ultra-rare ones, with their systemic repercussions, including toxic, genetic, peripartum, stress, diabetes, collagenosis, cardiogenetic interaction, as well as a vision of the future with artificial intelligence and 3D printing in cardiomyopathies.

Advances in imaging such as coronary computed tomography angiography in the non-invasive diagnosis of coronary artery disease, magnetic resonance imaging and its various specific evaluations of cardiomyopathies, nuclear medicine in microvascular disease and non-invasive diagnosis of transthyretin amyloidosis, and genetic tests have facilitated the recognition of different phenotypes. Moreover, based on the genotype of a given case, an entire family can also be identified related to preexisting clinical syndromes. Interaction between specialties and heart teams have improved care, disease management, and assistance of affected families. Accordingly, follow-up with a geneticist and genetic counseling are imperative in the era of personalized medicine.

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Review Article

Rare and Ultra-Rare Diseases as Causes of Cardiomyopathy

Diane Xavier Avila et al. Sandra Marques e Silva

Abstract

Several definitions of rare disease have emphasized the low prevalence of genetic diseases that can affect cardiac tissues and cause high psychosocial suffering due to the challenging diagnostic process and the high costs of complementary tests and specific therapies. In addition, there is the need for referral centers with different medical specialists, as well as nurses, social workers, psychologists, physiotherapists, among other professionals. With the rapid advances in genetics and precision medicine, associated with the emergence of specific therapeutic molecules (orphan drugs), many rare diseases are no longer “hidden” in pages’ footnotes, and their diagnoses cannot be neglected. The first step is to understand their physiopathogenesis, clinical signs and symptoms, and complementary diagnosis tools including genotyping. This review aims to present objective and important information to contribute to the investigation of the cardiovascular involvement in some of the rare genetic diseases.

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Review Article

Cardiac Sarcoidosis, the Great Chameleon of Myocardiopathies

Diogo Coutinho Suassuna et al. Felipe J. de Oliveira Fraga Carlos Eduardo L. Montenegro

Sarcoidosis is a chronic multisystemic disease of unknown etiology, histologically determined by the formation of non-caseating granulomas in various organs of the body, which can also affect heart tissues, resulting in cardiac sarcoidosis (CS).

This disease continues to be enigmatic in such a way that, since its first description (1929), and over the years, the exact mechanism of its pathogenesis has still not been clarified, with the possibility of the existence of an important component of genetic predisposition added to types of environmental exposure.

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Advances in Diagnosis and Treatment of Cancer Immunotherapy and CAR-T Cell–Related Myocarditis

Ariane Vieira Scarlatelli Macedo et al. Aurea Grippa Katia Regina Medeiros Luz Nathalia Coelho de Castro Nunes Sandrigo Mangini

Immune checkpoint inhibitors

The incidence of myocarditis in patients using ICI is low, around 1%. However, several series describe mortality between 30% and 40%. This is the primary reason that every effort is made for myocardial protection and early identification of signs of inflammatory response onset, in addition to understanding of T cell and macrophage stimulation and cytokine production.^, The onset of the lesion is most frequently observed observed early after the first dose of immunotherapy with a median time to onset of 30 days, with an average resolution of 90 to 120 days. Patients over 60 years of age are the most affected in the majority of series.

Patients with suspected ICI-associated myocarditis may develop from asymptomatic conditions with increased biomarkers to severe presentations including cardiogenic shock, ventricular arrhythmias, and sudden death. Dyspnea and asthenia are the most common complaints related to ICI-associated myocarditis; chest pain may also occur. The combination of ICI appears to be an important risk factor compared to monotherapy.

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Review Article

Tachycardiomyopathies

Luís Beck-da-Silva et al. Andreia Biolo

What are tachycardiomyopathies?

Tachycardiomyopathy is a relatively uncommon heart condition in which the myocardium develops ventricular dysfunction as a consequence of a persistently abnormal heart rhythm. One of the characteristics of this condition is that it is partially or completely reversible, once the arrhythmia has been controlled, making it crucial to recognize adequately in order to make recovery of ventricular function possible. In fact, the term “arrhythmia-induced cardiomyopathy” has emerged because tachycardiomyopathy results not only from prolonged and uncontrolled atrial or ventricular tachycardia, but also from atrial and/or ventricular ectopy leading to dyssynchrony. Both conditions can lead to chronic myocardial overload, resulting in ventricular dysfunction and heart failure.

Tachycardiomyopathies can be classified into two groups: in the first, arrhythmia is the only identified cause of ventricular dysfunction (arrhythmia-induced); in the second, the arrhythmia may aggravate ventricular dysfunction or worsen heart failure in a patient with pre-existing heart disease (arrhythmia-mediated).

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Review Article

Peripartum Cardiomyopathy

Walkiria Samuel Ávila et al. Regina Coeli Marques de Carvalho

Abstract

Peripartum cardiomyopathy (PPCM) is a low frequent, but potentially fatal disease, that manifests with heart failure and reduced ejection fraction, with no other identified cause, and related to the puerperal pregnancy cycle. It is a global disease with different clinical manifestations and prognosis. Known risks include preeclampsia, advanced maternal age, multifetal gestation, and African ascendence. Genetic tests have shown that up to 20% of women with PPCM have an identifiable variant of cardiomyopathy. The etiopathogenesis of PPCM, although still unclear, is characterized by endothelial dysfunction caused by anti-angiogenic agents in the placenta, and prolactin degradation products. Clinical manifestation of PPCM does not differ from that of heart failure in other cardiomyopathies, with symptoms varying from mild to cardiogenic shock. Mortality rates in PPCM patients vary widely, and are related to cardiogenic shock, thromboembolism, and complex arrhythmias. The disease may progress rapidly to severe HF, with indication for mechanical circulatory support or cardiac transplant. The treatment of PPCM during gestation is distinct due to potential adverse effects of drugs to pregnancy. However, a careful selection of beta-blockers, diuretics and vasodilators has achieved therapeutic success for the mother and the fetus. Although the treatment meets traditional guidelines developed for nonpregnant adults, the use of bromocriptine (ergot alkaloid) and cabergoline (dopamine D2 receptor agonist) has shown favorable results in ventricular recovery in patients with LVEF < 35% when treated with optimized treatment for heart failure.

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Review Article

Conduction Disturbances Leading to Heart Failure – What Clinicians Need to Know

Estêvão Lanna Figueiredo et al. Frank Nunes Fernando Carvalho Neuenschwander Kleisson Antônio Pontes Maia André Assis Lopes do Carmo

Abstract

Recently, pre-excitation syndromes, left bundle branch block (LBBB), and right ventricular pacing have been recognized as causes of cardiomyopathies (CMs). They all have abnormal ventricular activation, that results in what is known as left ventricular (LV) dyssynchrony. These three entities show a common feature of wide QRS and LBBB pattern on the electrocardiogram. The term abnormal conduction-induced CM was, then, proposed. Appropriate diagnosis and treatment of these CMs will possibly improve LV ejection fraction, LV functional capacity and reduce morbidity and mortality. In this article we will briefly review these three clinical conditions, aiming to help clinicians to recognize them, manage and refer patients at risk.

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Review Article

Advances in Clinical Practice, Diagnosis and Treatment of Chronic Chagas’ Heart Disease

Sílvia Marinho Martins Alves et al. Bárbara Mariana dos Santos Silva Esthefany Dias Barbosa Carolina de Araújo Medeiros … Maria das Neves Dantas da Silveira Barros Maria da Glória Aureliano de Melo Cavalcanti Maria Elisa Lucena Sales de Melo Assunção Virginia Maria Barros de Lorena Afonso Luiz Tavares de Albuquerque Renata Amorim de Lucena Carlos Eduardo Lucena Montenegro Clodoval de Barros Pereira Júnior Lucas Reis da Costa Cristina de Fátima Velloso Carrazzone Wilson de Oliveira Júnior

Abstract

Chagas disease has become globalized as a result of the migratory process of infected patients to non-endemic areas. With the considerable number of individuals affected by the disease, detection and treatment of its chronic manifestations is a relevant and necessary issue. Growing attention has been paid to chronic Chagas cardiomyopathy (CCC), which includes heart failure, malignant arrhythmias, conduction disturbances and thromboembolic events. Many pharmacological and non-pharmacological treatments for CCC are still extrapolations of existing evidence on the treatment of other clinical conditions, highlighting the need of including this group of patients in future studies. In this review, we will discuss the most recent data from the literature and clinical practice on the diagnosis and treatment of CCC.

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Restrictive Cardiomyopathies: What’s New on the War Front?

Luiz Claudio Danzmann et al. Liciani de Mello Feliciano Elisa Kalil Paula Loredo Siminovich Marianna de Moura Nora

A rare – or not so rare – condition?

Restrictive cardiomyopathies, caused by primary pathologies of the heart muscle, are considered rare diseases, corresponding to about 5% of all cardiomyopathies. The most frequent form of restrictive cardiomyopathy is cardiac amyloidosis (CA), which can be considered a benchmark since, with the availability of diagnostic technologies, its detection has been made much more frequent, associated with the fact that there are effective treatment possibilities.

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Post-COVID Cardiomyopathy

Marcio Roberto Moraes de Carvalho et al. Jocemir Ronaldo Lugon Antonio Jose Lagoeiro Jorge

Myocardial inflammation, COVID-19, and HFpEF

Myocardial inflammation is widely considered to be one of the main factors in the development of heart failure (HF). It is believed that persistent myocardial inflammation plays a central role in the development of adverse left ventricular remodeling after myocardial infarction, as well as in the pathogenesis of dilated cardiomyopathy and heart failure with preserved ejection fraction (HFpEF).^–

In May 2020, Tavazzi et al. reported the first case of acute cardiac injury with the finding of SARS-CoV-2 particles and low-grade inflammation in the myocardium, not accompanied by cardiomyocyte necrosis. An important discussion is whether the myocardial changes are caused by direct viral damage to the heart or vasculature or by a cytokine storm related to the infection. It is mainly known that cardiac inflammatory changes induced by viruses are capable of triggering HFpEF and heart failure with reduced ejection fraction. There is currently a growing interest in identifying patients with COVID-19 at risk of developing virus-related HF and cardiovascular problems.

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