Malaria has many serious cardiovascular complications, and typical antimalarial therapies carry an increased risk of fatal cardiac side effects. This shows the importance of screening these patients for possible heart involvement. This perspective was set out in a review published in the Journal of the American College of Cardiology.
Studies of cardiovascular abnormalities and malaria were searched through publication databases. A total of 28 case reports, reviews and studies as well as 1 randomized controlled trial were included in this analysis.
Patients with malaria infection have fever, flulike symptoms, and myalgia. Stage 1 is characterized by severe tremors. Stage 2 includes fever, headache, nausea, vomiting, and myalgia for 3 to 7 hours. During the third stage, other symptoms begin to subside, but the patient sweats profusely for about 4 hours.
Immediate identification and treatment is needed to avoid potentially serious complications. Pregnant women, older adults, children and people with co-existing diseases are at increased risk of serious malaria infections.
Possible complications of malaria are decreased cardiac output, conduction disorders, myocarditis, pericarditis, arrhythmias, cardiac tamponade, and heart failure. The direct effects of malaria on the cardiovascular system are still poorly understood, but hypotheses include erythrocyte sequestration and the pro-inflammatory cytokine response.
Infected red blood cells show an increased expression of adhesion membrane proteins, which affect the microcirculation and can cause increased cytoadherence of the endothelial cells. Proinflammatory cytokines can induce a loss of energy in myocardial cells, and the plasmodial toxin can induce apoptosis among cardiomyocytes.
In addition, malaria is associated with severe anemia, which can cause cardiac stress or left ventricular hypertrophy. Anemia can also lead to acute kidney failure.
There are no generally accepted recommendations for diagnosing possible cardiovascular involvement in patients with malaria. In a prospective cohort of patients with malaria, an electrocardiogram found cardiovascular involvement in 17% of participants. Another study used electrocardiograms and echocardiograms to find that 26% of participants had signs of cardiovascular involvement.
The review authors suggest that patients with signs of complicated malaria, high parasitemia, or signs of cardiovascular involvement be screened by electrocardiogram and for cardiac biomarkers such as troponin T or N-terminal natriuretic peptide of the pro-B type. If abnormalities are found, these patients should be further evaluated with an echocardiogram or magnetic resonance imaging.
In addition to typical intravenous quinidine therapy and continuous monitoring in patients with severe malaria, symptom-specific therapy may be required in patients with cardiovascular involvement. For example, patients with myocarditis or pericarditis should be treated with anti-inflammatory therapy and possibly steroids.
Heart or kidney failure may require diuretics, fluids, or transfusions. Patients with signs of arrhythmia may need additional monitoring. Some antimalarial drugs, such as mefloquine, may be poor treatment candidates because they have been linked to sinus bradycardia or QTc interval prolongation.
This study was limited by the underlying studies. Many had an observational design with a brief follow-up examination. Cardiovascular involvement may not have been adequately reported and the long-term consequences remain unclear.
The review authors concluded that early detection of cardiovascular involvement in patients with malaria infection is essential for the effective administration of interventions and the avoidance of long-term complications.
Additional research is needed to better understand the relationship between the cardiovascular system and malaria infection.
Gupta S., Gazendam N., Farina JM, et al. Malaria and the heart. State of the art JACC review. J Am Coll Cardiol. 2021; 77 (8): 1110- 1121. doi: 10.1016 / j.jacc.2020.12.042
This article originally appeared on The Cardiology Advisor