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In addition, COVID patients with preexisting cardiovascular comorbidities have a higher risk of death. Main cardiovascular complications of COVID are myocardial infarction, myocarditis, acute myocardial injury, arrhythmias, heart failure, stroke, and venous thromboembolism. In other words, the global pandemic of COVID infection is still serious, although vaccines from different countries and companies have been used worldwide Dong et al. Therefore, it is necessary to discuss the adverse effects of different therapies. In particular, children with COVID have also been reported to develop hyperinflammatory shock with characteristics similar to Kawasaki disease, including abnormalities of the coronary vessels and cardiac dysfunction Akca et al. Common cardiovascular complications of COVID are arrhythmias, direct cardiac injury, fulminant myocarditis, acute myocardial infarction, heart failure, pulmonary embolism, and disseminated intravascular coagulation Aid et al. However, to date, little is known about the cardiovascular complications of anti-COVID drug therapy. All the four figures indicate that the major complications of COVID are the cardiovascular related diseases. Current common anti-COVID therapies include antiviral treatment, immunotherapy, convalescent plasma, traditional Chinese medicine, oxygen therapy, nutritional support, mechanical ventilation, and nursing care CDC, b ; Inglis et al. It is important to understand in-depth the cardiovascular complications of anti-COVID therapy to further define the benefit of drug treatment strategies. However, the main pathways of cardiovascular complications of anti-COVID drugs have been proposed are listed as follows Figure 2 : 1 direct cardiotoxicity; 2 systemic inflammation; 3 mismatch of myocardial supply and demand; 4 plaque rupture and thrombosis of coronary; 5 disseminated intravascular coagulation due to sepsis; 6 imbalances of electrolyte; 7 endotheliitis and 8 hypercoagulability Bansal, ; Kang et al. There is a common consensus that receptor-mediated endocytosis is the main way for the virus to enter cells. ACE2 can be recognized by the spike S protein on the surface of SARS-CoV-2, and their combination enable the virus to enter human cells in term of attachment, fusion and entry. S protein compose of S1 subunit containing receptor-binding domain RBD which can bind to host receptor and S2 subunit fusing the viral and host membranes. Therefore, both ACE2 and S protein can serve as targets for the development of entry inhibitors, antibodies, and vaccines. The most severe cases of COVID are characterized by an acute systemic inflammatory response, cytokine storm, endotheliitis, and hypercoagulability. Increased of systemic inflammation and shear stress due to elevated coronary blood flow causes plaque rupture and subsequent arrhythmias, acute myocardial infarction, and heart failure. It is well known that endothelial cells play a crucial role in the maintenance and regulation of vascular homeostasis and coagulation. Endodermatitis, characterized by endothelial dysfunction and hypercoagulability, is a common feature of major comorbidities that increase the risk of severe COVID Becker, ; Fan et al. Common treatment of COVID patients with cardiovascular complications includes traditional care, coronary angiography and percutaneous coronary intervention if indicated, the use of anticoagulants and antiplatelet agents, and supportive care. Some patients with circulatory collapse may need extracorporeal circulatory support. TABLE 1. Antiviral and anti-inflammatory drugs that have been suggested for the treatment of COVID infection. Lopinavir inhibits the action of the enzyme 3-chymotrypsin-like protease and P-glycoprotein, which plays a crucial role in the distribution and elimination of lopinavir Zhang et al. Ritonavir is used in combination with lopinavir because it can increase the half-life of lopinavir by inhibiting the metabolizing enzyme cytochrome P 3A Abbvie, However, it has recently been shown to be ineffective according to a randomized controlled trial Cao et al. Interestingly, common adverse reactions of the combination of lopinavir and ritonavir include hypertension, prolonged P-R and prolonged QT interval, torsade de pointes, severe conduction disorders, and cardiac arrhythmias Badiou et al. Therefore, changes in electrocardiograms and alteration of blood lipids should be monitored and checked in patients with COVID and dyslipidemia. The course of treatment lasts less than 10 days. Remdesivir is an inhibitor of viral RNA-dependent RNA polymerase RdRp with broad-spectrum activity against several members of the virus family such as coronaviruses e. It is usually used in hospitalization of patients who require supplemental oxygen. Although remdesivir has a numerically faster time to clinical improvement than placebo in patients, there was no statistically significant difference between the two groups. Notably, remdesivir is not recommended for mild patients due to a high incidence of adverse events Wang et al. Another larger study confirms that remdesivir was superior to placebo in shortening recovery time and reducing the incidence of adverse events Beigel et al. Known adverse events of remdesivir are hypotension, bradycardia, QTc prolongation, and T-wave abnormality Gubitosa et al. In addition, it causes endothelial dysfunction by promoting the expression of factors related to oxidative stress Buie et al. Although the drug is administered locally in the respiratory tract, one should be vigilant of its cardiotoxicity and pay close attention to electrocardiogram changes, the development of acute myocardial infarction, and heart failure, especially in elderly patients with preexisting cardiovascular diseases. Ribavirin is a purine nucleoside analogue with broad-spectrum antiviral activity, which can effectively inhibit the proliferation of a variety of respiratory viruses. It is administered in different ways in various diseases Ma et al. This drug can also be used in both pediatric and adult populations co-infected with hepatitis B and HIV. Wang et al. Common adverse reactions of ribavirin include dyspnea and chest pain, especially in patients with COPD and asthma Lu et al. Long-term lasting 13 days and high-dose mg twice per day ribavirin increased the risk of developing cardiovascular disease events and raised the risk of death in patients with cardiovascular disease Beigel et al. Ribavirin can induce mitochondrial toxicity and energy metabolism disorders of cardiomyocytes by promoting mitochondrial calcium metabolism disorders Lafeuillade et al. Therefore, ribavirin may increase the risk of cardiac dysfunction in patients with preexisting cardiovascular diseases. Chloroquine is used mainly in the treatment of malarial and rheumatic diseases Savarino et al. It served to treat COVID patients due to the characteristic of inhibiting endosomal acidification required for virus-host cell fusion. Chloroquine has been the drug of choice for large-scale use in the treatment of COVID patients due to its wide availability, proven safety record, and relatively low cost Cui et al. However, excessive use of chloroquine can cause cardiovascular dysfunction such as hypotension, hypokalemia, QRS and QT prolongation, atrioventricular block, arrhythmias, and even coma Wong, In addition, COVID patients receiving a combination of hydroxychloroquine and azithromycin had a longer QT interval than those taking hydroxychloroquine alone in a cohort study Mercuro et al. Furthermore, recent studies demonstrated that chloroquine and hydroxychloroquine were not effective drugs for COVID Brown et al. The therapeutic dose of drugs is in a narrow concentration range that requires appropriate doses for different populations. PCQ can control the electrophysiological activity of the heart by regulating the energy metabolism of cardiac myocytes, voltage-gated ion channels, calcium channel, and electrochemistry transporters Mubagwa, However, CQ can induce serious cardiovascular reactions such as arrhythmias, shock, and Adams-Stokes syndrome Pareek et al. Recently, several reviews have noted out that CQ and HCQ induce significant prolongation of the QT interval and potentially increase the risk of serious arrhythmias and sudden death Aggarwal et al. Previous studies have shown that HCQ can reduce cardiovascular risk, especially the incidence of cardiac dysfunction in patients with myocardial infarction Liu et al. There is no association between HCQ administration and the risk of composite endpoint of intubation or death based on an observational study Geleris et al. It was identified as the numb-associated kinase inhibitor NAK with selectivity of the adapter protein-2 complex AP2 -associated protein kinase 1 AAK1 and cyclin G-associated kinase GAK that are mediators or regulators of viral endocytosis Stebbing et al. Inhibition of AAK1 by baricitinib can interrupt virus entry into cells and subsequently stop intracellular assembly and virus replication. A recent study found that baricitinib improved clinical conditions in 12 patients with mild and moderate COVID Cantini et al. Another study demonstrated that baricitinib had a lower fatality rate and admission to the ICU, but a higher discharge rate compared with controls at week 1 and week 2 Cantini et al. However, baricitinib was not recommended to treat patients with severe COVID with susceptible constitution, at least be cautious Favalli et al. The common adverse effect of baricitinib on COVID is hyperglycemia, infections, and thromboembolic events. Arbidol is a non-nucleoside antiviral drug mainly for the treatment of influenza and other viral infections, which has inhibitory effects on both enveloped and nonenveloped viruses Boriskin et al. As a highly selective hemagglutinin inhibitor, arbidol can effectively target the hemagglutinin fusion machinery and prevent CoVs from anchoring the cell surface and invading cells Blaising et al. Common cardiovascular adverse effects of arbidol include nausea, diarrhea, dizziness, liver injury, vomiting, and bradycardia. The recommended dose of arbidol for COVID patients is mg PO each time and three times per day, and the course of therapy is not longer than 10 days. Other common candidate antiviral drugs for COVID are fapiravir, penciclovir, sofosbuvir, and galidesivir Pillaiyar et al. Their main adverse effects include hypotension and arrhythmias. Fapiravir is a broad-spectrum anti-influenza drug, which exerts an antiviral effect mainly by inhibiting RNA synthetase Gao et al. Sofosbuvir is an FDA-approved drug that is mainly used to treat patients with hepatitis C with various genotypes. Sofosbuvir is converted in a host cell to its active form, nucleoside triphosphate through phosphorylation, which terminates RNA replication in the nascent viral genome through competition with the nucleotides of invasive viruses Sayad et al. However, these drugs have their own cardiovascular risk. For example, Mulangu et al. Caldeira et al. Taken together, cardiovascular complications and risks of antiviral drugs need to be taken into account when used in COVID patients. Anti-inflammatory and immunotherapy drugs can alter the workings of the immune system, so it can find, attack, and eliminate invasive pathogens and finally get rid of them. Thus, it is an efficient therapeutic option against viral infections, including patients with COVID characterized by the cytokine storm Aminjafari and Ghasemi, ; Blanco-Melo et al. Dexamethasone, as a representative anti-inflammatory drug, is a broad-spectrum immunosuppressor approved by the FDA with high activity and a long duration of action. It will inhibit the release and subsequent detrimental effect of cytokines to further combat symptoms of hyperinflammation or cytokine storm in COVID Lim and Pranata, ; Sharun et al. However, there is a lack of clinical benefit of dexamethasone in non-critical patients without respiratory support such as ventilation or oxygen Johnson and Vinetz, ; Lester et al. Dexamethasone can increase mortality in patients without critical illness who did not receive respiratory support Matthay and Thompson, It is notable that a low dose of dexamethasone could only reduce the mortality of patients with severe COVID, but had no effect on the mortality of patients with mild and moderate COVID patients; while high doses of dexamethasone contributed to more harm than good Ahmed and Hassan, ; Prescott and Rice, ; Sterne et al. Additionally, the combination of dexamethasone and remdesivir may reduce mortality, which has been recommended to treat COVID patients with mild-moderate conditions Garibaldi et al. It is worth noting that dexamethasone treatment can lead to several adverse effects such as arrhythmias, headache, agitation, dizziness, and increased appetite. However, the adverse effects of tocilizumab should not be ignored, such as cardiomyopathy and liver injury Muhovic et al. Gabay et al. The most common adverse reactions and events were infections that were characterized by an increase in serum cholesterol, ALT, AST, and injection site reactions Khiali et al. Luo et al. Xu et al. The average discharge time of patients treated with tocilizumab was It is worth of mentioning that an increasing trend of IL-6 occurs immediately when tocilizumab usage is reduced. Alattar et al. Morena et al. Hermine et al. Fu et al. It should be used with caution in patients with dyslipidemia and hypertension. Anakinra is one of the anti-interleukin 1 antagonist which can inhibit actions of IL-1 receptor to suppress the pathogeny of proinflammatory cytokine storm in COVID Aouba et al. Several studies indicated that anakinra is a safe and effective drug combating COVID patients with cytokine storm signs Bilia et al. Cavalli et al. Langer-Gould et al. Kooistra et al. The main adverse effects of anakinra were hypersensitivities, hyperinfammation, breathing problem, nausea, vomiting diarrhea, headache, and joint pain Hossen et al. Adequately powered and randomized controlled trials are needed to confirm the efficacy of convalescent plasma therapy for COVID Bloch, ; Liu et al. Recently, several randomized controlled trials demonstrated that the efficiency in different cases using plasma convalescent therapy is inconsistent Agarwal et al. The general known cardiovascular risks of plasma transfusion generally include transfusion-associated circulatory overload, hypercoagulablility, and thrombosis Sanfilippo et al. Traditional Chinese Medicine TCM is usually defined by a mixture of herbal plants or their extracts which comprise hundreds of constituents with various differing physiochemical properties Zhou, TCM is a unique health resource in China, which is also a vast and large untapped resource in the world. For example, artemisinin, a safe and effective antimalarial drug, was originally extracted from Artemisia annua by TCM scientific workers Tu, Several TCMs have been recommended by the China National Health Commission to treat COVID patients because the advantages far outweigh the disadvantages, which are characterized mainly by promoting neutrophil-mediated inflammation and reducing macrophage-mediated anti-inflammatory activity Wang et al. Different of the above-mentioned TCMs are used to treat different diseases and different courses of the same disease Table 2. The key mechanism of TCM is inflammation regulation Li et al. In addition, TCM controls cardiovascular risk factors such as hypertension and diabetes Hao et al. A combination of drugs can on one hand be beneficial and on the other hand harmful because of side effects. Lopinavir and ritonavir are metabolized by CYP3A and interact with a variety of antiarrhythmic drugs, such as amiodarone and digoxin, which can increase the risk of adverse cardiovascular events. Antiviral drugs such as ritonavir can interact with nonvitamin K-dependent oral antiplatelet agents such as clopidogrel. There are drug interactions between arbidol and CYP3A4 inhibitors or inducers, and long-term use of arbidol and CYP3A4 inhibitors or inducers can lead to cardiac toxicity Liu et al. Generally, it is not recommended to use three or more antiviral drugs at the same time. In case of intolerable adverse effects, the relevant drugs should be stopped NHC, a. Inappropriate use of antibacterials, especially the combination of three or more broad-spectrum antibacterial drugs should be avoided in patients with COVID infection because that there were many complications such as hypertension, hyperglycemia, fever, dry cough, and dyspnea Yang et al. Although corticosteroids have the action to reduce the severity of myocarditis and cytokine storm in COVID patients, they inhibit viral RNA clearance. In addition, the intravenous transplantation of mesenchymal stem cells MSC can improve the condition of patients with COVID, especially for critical cases Leng et al. The principles of treatment in severe and critical cases include symptomatic treatment, prevention of complications and secondary infections, treatment of underlying diseases, and timely maintenance of organ function. The main measures of organ function support are respiratory support oxygen therapy and mechanical ventilation , circulatory support liquid balance strategy, improvement of blood circulation with hemodynamic monitoring , and renal replacement therapy in patients with renal dysfunction, plasma therapy from convalescent patients, and blood purification plasma exchange, adsorption, perfusion, filtration NHC, b. Once COVID patients are treated, medical personnel must pay attention to baseline cardiovascular health and adjust the treatment plan in time according to changes in heart rate, blood pressure, blood lipids, cardiac function, and electrocardiogram. Medical staff should also take note of drug-drug interactions to avoid drug-induced myocardial injury. In addition, indexes of myocardial injury and cardiac function should be monitored by combining laboratory and imaging results. Clinicians need to continue to assess the efficacy of combination drugs. Combining of three or more antiviral drugs is not recommended, especially in elderly patients. Although progress has been made in the search for drugs to treat infection, a reliable drug screening model in vitro and in vivo should be built with collaborative innovation. DL and XZ generated the concept for this review, performed the literature search, and contributed equally to this work. DL and XW guided the study. All authors have read and approved the final manuscript. The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher. Abbvie Kaletra Prescribing Information. Available from www. Accessed May 12, Google Scholar. Maryland: DailyMed. Agarwal, A. BMJ , m Aggarwal, G. Cardiol , — Ahmed, M. SN Compr. Aid, M. Cell 5 , — Akca, U. Akhmerov, A. Alattar, R. Tocilizumab for the treatment of severe coronavirus disease Alizargar, J. Aminjafari, A. An, X. Aouba, A. 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Disclaimer: All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. Top bar navigation. About us About us. Sections Sections. About journal About journal. Article types Author guidelines Editor guidelines Publishing fees Submission checklist Contact editorial office. TABLE 2.

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