**3. Treatment in the light of cardiovascular disease**

Regarding the treatment of the COVID-19 infection there are many trials from the beginning of April 2020. Based on the evidence we have so far, the treatment depends on clinical presentation, laboratory and imaging findings as indicated. Supportive care, starting from symptomatic measures, up to complete intensive care support is recommended [48].

There is a need of more research concerning the relationship between renninangiotensin-aldosterone blockade and COVID-19 disease in patients with cardiovascular conditions. From the recommendations and guidelines of the major cardiology societies we have so far, therapy with ACE inhibitors or angiotensin receptor blockators for other indications should not be discontinued [28, 49]. The evidences we have do not indicate increased risk of infection or worse clinical course in patient treated with these medications. From other side we have strong warnings

that discontinuation of the therapy with these drugs, which modifies prognosis in patients with cardiovascular disease, may increase cardiovascular mortality rates [50]. In heart failure patients the use of drugs that may alter salt and water balance and cause excessive fluid accumulation, such as non-steroid anti-inflammatory drugs (NSAID) should be avoided. Advanced heart failure should be treated and monitored by cardiologists, based on the latest guidelines for the management of heart failure [28].

In patients with COVID-19 disease and established CAD the use of drugs that stabilize plaques and modifies prognosis (statins, aspirin, beta blockers, ACE inhibitors) should be used as indicated in the current guidelines [51, 52]. We should minimize or avoid the use of diagnostic tests that are unnecessary and will not change the diagnostic and treatment decisions. Unnecessary diagnostic tests should be minimized, or in some cases avoided. These tests should be used in circumstances in which they could add to the management of patients with COVID-19. Prophylactic anticoagulation should be applied in all hospitalized patients with COVID-19 infection. Patients with acute confirmed PE should be treated based on risk stratification as recommended in the latest European Society of Cardiology (ESC) guidelines and National PERT Consortium [28, 46, 47].

#### **3.1 Knowledge gaps and future directions**

COVID-19 has emerged as a new disease almost one year ago and it is still impossible to discuss long-term outcome in patients recovering from infection. Impaired heart function due to myocardial damage in acute phase leads to poor prognosis in these patients. Follow up studies and more data are needed to make conclusions.

There are still many challenges, undiscovered mechanisms, pathobiology, clinical characteristics and prognostic markers of the COVID -19 disease which are continuously studied. Early signs and markers of myocardial injury and presence of new or worsened heart failure are bad prognostic parameters. Long term COVID-19 syndrome and post COVID cardiovascular repercussions are another field of ongoing and future research. Special attention should be taken on timely diagnosis, management and follow up of the cardiovascular complications of COVID-19 disease.

The current evidence of association between renin-angiotensin-aldosterone medications and ACE-2 levels with clinical outcome in COVID-19 infection is insufficient. More information needs to be generated.

#### **4. Conclusion**

Preexisting cardiovascular disease are common in patients with COVID-19 and those patients are at higher risk of morbidity and mortality. Myocardial injury is present in more than a 15% of severely ill patients. The interaction between the virus S protein and ACE 2 is believed to have important role in disease pathogenesis, especially in cardiovascular manifestations, that could be potential target for the prevention and treatment of COVID-19 infection. The continuation of clinically indicated ACEi or ARB therapy is recommended by many heart associations, based on the currently available evidence. Reduced physical activity due to lockdown measures also contribute to worsened control of cardiovascular risk factors. Having in mind the prevalence of cardiovascular complications our main strategy to fight the pandemic remains social distancing, personal protection, vaccination and regular therapy for all cardiovascular disease patients.

*COVID-19 and Cardiovascular Disease: Mechanisms and Implications DOI: http://dx.doi.org/10.5772/intechopen.99332*
