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COVID-19 and cardiovascular disease: a lethal syndemic

The COVID-19 pandemic is not just a virus-related healthcare crisis. It has major implications and interactions with chronic non-communicable diseases, cardiovascular disease in particular, that increase the impact of the emergency. This is amplified by social, economic and regional inequities, which are closely linked to the prevalence of cardiovascular disease, worsening the situation. Even air pollution and climate change play a role, making the COVID-19 crisis a syndemic rather than a traditional global viral epidemic.

Although we read daily about the coronavirus (COVID-19) pandemic, this has been more properly defined as a syndemic. A syndemic is the synergistic aggregation of two or more concurrent categories of disease clustering in the population within social groups according to patterns of health disparity or inequality, exacerbating the prognosis and/or the burden of each separate disease. The pandemic of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection has a strong biological, pathophysiological and social interaction with the cardiovascular system and cardiovascular disease (CVD). This means that preventive or therapeutic strategies based only on cutting viral transmission lines may not be totally effective to protect the health of every community [1].

The interactions between COVID-19 and the cardiovascular (CV) system are multiple [2]: the role of the CV system on the COVID-19 pathophysiology is well known. SARS-CoV-2 uses the angiotensin-converting enzyme 2 (ACE 2) receptor, a critical player in the homeostasis of the cardiovascular system and in the pathophysiology of CVD, as the entry point to penetrate and infect human cells [3]. The role of the cardiovascular system on the pathophysiology of COVID-19 is so important that it has been defined as an endothelial disease [4].

SARS-Cov2 infection and the associated inflammatory state has direct and indirect effects on the CV system, including acute myocarditis, heart failure decompensation, increased risk of arrhythmias and, notably, a prothrombotic state leading to venous and arterial thrombotic events, most often pulmonary embolism [5].

The higher vulnerability of patients with cardiovascular risk factors or with CVD to severe COVID-19 and to COVID-19 death was identified early and has been confirmed by several observational and epidemiological studies and meta-analyses [6].

As mentioned before, a key feature of a syndemic is the heterogeneity of the impact according to social or economic inequalities. We see this in the more severe impact of COVID-19 on the most deprived populations. Although the several waves of COVID-19 have spread the disease throughout all social strata, the evidence illustrates the disproportionate burden of COVID-19 deaths among racial and ethnic minority groups [7, 8], women [9], and the most deprived neighbourhoods of cities in developed countries as well as in the regions with the highest prevalence of chronic non-communicable diseases, most notably CVD [10, 11]. Moreover, COVID-19 mortality has been correlated to the levels of all sources or fossil fuel-dependent air pollution [12], and therefore calls to join actions to reduce air pollution and emissions and move to a zero-emission economy have been published [13].

However, COVID-19 has also had a major impact on the epidemiology of CVD. Several reports from around the world have communicated, during the major waves of COVID-19, decreases in hospitalisations for acute cardiovascular conditions, such as acute coronary syndromes or heart failure, drops in cardiac non-invasive and invasive/surgical procedures, delays in cardiovascular care times (i.e., reperfusion times for ST-segment elevation acute myocardial infarction, waiting times for scheduled interventions…), reduction in the attention of out-of-hospital cardiac arrest, and worsening in their short-term outcomes and, finally, increases in the rates of some types of cardiovascular death.

Unfortunately, the effective solutions developed to overcome this tragic situation are heavily conditioned by socioeconomic conditions, limiting their availability to the most threatened segments of the population. The major inequalities in the access to any of the effective COVID-19 vaccines, which have been able to improve the situation, are not reducing but rather increasing the gap between privileged and less privileged society groups or countries [14].  There are still unmet needs that we need to overcome and solutions that need to be determined in such topics as the impact of COVID-19 on CV care and the social determinants of vaccination.

Take-home message

COVID-19 is not just a viral pandemic but a syndemic; the interaction between an epidemic and the presence of chronic, non-communicable diseases amplified by social, economic, and regional inequities of many kinds. Virus-centred interventions, although essential, will fall short of reducing the global impact of Covid-19. We need to take a wider approach and use this crisis as an opportunity to improve health globally.


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Notes to editor


Héctor Bueno1,2,3,4 , MD, PhD

  1. Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain; 
  2. Cardiology Department, Hospital Universitario 12 de Octubre and Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), Madrid, Spain;
  3. Centro de Investigación Biomédica en Red Enfermedades Cardiovaculares (CIBERCV), Madrid, Spain;
  4. Facultad de Medicina, Universidad Complutense de Madrid, Madrid, Spain.


Address for correspondence:

Professor Héctor Bueno, Melchor Fernández Almagro, 3, 28029 Madrid. Spain


Author disclosures:

Dr. Bueno receives research funding from the Instituto de Salud Carlos III, Spain, Sociedad Española de Cardiología, AstraZeneca, Bayer, PhaseBio and Novartis, he has received consulting fees from AstraZeneca, Novartis and Organon, speaking fees from Novartis, and is a scientific advisor for MEDSCAPE-the heart.og.


The content of this article reflects the personal opinion of the author/s and is not necessarily the official position of the European Society of Cardiology.