What are the cardiac effects of mild dengue in a patient with a history of Covid-19 (Coronavirus disease 2019)?

Cardiac Effects of Mild Dengue in Patients with Prior COVID-19 History

Patients with mild dengue who have a history of COVID-19 should undergo focused cardiac evaluation due to potential additive cardiac effects from both infections, including ECG monitoring, echocardiography, and cardiac biomarker testing.

Potential Cardiac Manifestations

Mild dengue infection in patients with prior COVID-19 may present with overlapping cardiac effects due to the potential for both viruses to affect the cardiovascular system:

Common Cardiac Effects in Mild Dengue

• Rhythm disturbances: Sinus bradycardia is the most common abnormality (19.7% of dengue patients), despite fever 1
• Arrhythmias: Atrial (4.9%) and ventricular (4.0%) extrasystoles 2
• Myocardial involvement: Approximately 15% of dengue patients may show elevated troponin-T levels 1
• Left ventricular dysfunction: About 13.1% of dengue patients may develop left ventricular ejection fraction less than 40% 1

COVID-19 Cardiac Sequelae That May Persist

• Post-acute COVID-19 syndrome (PASC): Cardiovascular symptoms may persist beyond 4 weeks after infection 3
• Chest pain: May result from endothelial dysfunction or coronary vasospasm 3
• Tachycardia: Inappropriate sinus tachycardia or postural orthostatic tachycardia syndrome (POTS) 3
• Myocardial inflammation: May persist for months after COVID-19 infection 3

Evaluation Approach

For patients with mild dengue and history of COVID-19:

1. Initial Assessment:

   • 12-lead ECG to detect arrhythmias, conduction abnormalities, or ST-T changes
   • Cardiac biomarkers (troponin, CK-MB, NT-proBNP) to assess for myocardial injury
   • Focused cardiac ultrasound (FoCUS) to evaluate:
     • Left ventricular systolic function and dimensions
     • Right ventricular function (RVFAC or TAPSE)
     • Presence of pericardial effusion 3

2. Monitoring Parameters:

   • Heart rate patterns (bradycardia despite fever is particularly concerning)
   • Blood pressure (hypotension may indicate myocardial dysfunction)
   • Oxygen saturation (lower values correlate with cardiac involvement) 4

3. Risk Stratification Factors:

   • Advanced age (OR=1.70)
   • Male sex (OR=1.94)
   • Decreased platelet count (OR=1.13)
   • Presence of warning signs (OR=3.29) 2

Management Considerations

Management should be tailored based on the severity of cardiac involvement:

For Patients with Minimal/No Cardiac Involvement:

• Supportive care with judicious fluid management
• Regular monitoring of vital signs
• Follow-up ECG after recovery

For Patients with Evidence of Cardiac Involvement:

• Consider hospitalization for monitoring if any of the following are present:

  • New-onset chest pain/pressure
  • Worsening dyspnea disproportionate to fever
  • New arrhythmias
  • Unexplained tachycardia persisting after fever resolution
  • Rising cardiac biomarkers 5

• For myocardial involvement:

  • Avoid NSAIDs due to risk of increased inflammation and mortality 5
  • Consider ACE inhibitors/ARBs unless hemodynamically compromised 5
  • Continue beta-blockers in hemodynamically stable patients 5

Follow-up Recommendations

For patients who had evidence of cardiac involvement:

• Surveillance testing at 3-6 months, including ECG, echocardiogram, and cardiac MRI if indicated 3
• Abstinence from competitive sports and strenuous exercise for 3-6 months
• Return to activity only when:
  • Absence of cardiopulmonary symptoms
  • Resolution of laboratory evidence of myocardial injury
  • Normalization of LV systolic function
  • Absence of arrhythmias 5

Important Caveats

• Most cardiac manifestations in mild dengue are self-limiting (83.3%) and occur in the first days of fever onset (75%) 2
• Uncomplicated COVID-19 survivors typically show normal ventricular and atrial functions at 6 months post-infection 6
• The absence of ECG abnormalities, echocardiogram findings, or elevated cardiac markers has a 100% negative predictive value for adverse outcomes in dengue 1
• Patients with pre-existing cardiovascular disease are at higher risk for complications from both infections and require closer monitoring 3