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We stay at home and prepare ourselves in order to limit the consequences of the COVID-19 pandemic. Properly informing society as a whole is an obligation of the medical community in the effort to protect population groups at increased risk of severe illness from the virus.

We constantly hear that cardiovascular patients belong to high-risk population groups, and we continuously receive questions from patients regarding their individual circumstances. The spectrum of cardiovascular diseases is extremely broad, and it is clear that the level of risk varies significantly depending on the specific condition.

Based on recent epidemiological data, patients at very high risk of an adverse outcome from COVID-19 include those with congestive heart failure, severe valvular heart disease and pulmonary hypertension. These are patients who already experience shortness of breath and easy fatigability and are unable to carry out their daily activities.

With regard to coronary artery disease, we need to take into account the history of myocardial infarction, its extent, as well as the extent of coronary artery disease and whether myocardial ischemia is present. More specifically, a patient with a previous extensive myocardial infarction and incomplete revascularization who experiences angina or shortness of breath is at high risk, whereas a patient who has undergone single-vessel angioplasty without a previous infarction and has had a recent negative ischemia test does belong to a vulnerable group, but is clearly at lower risk.

Valvular heart diseases also constitute a disease category with a very broad risk spectrum. The majority of people who undergo cardiac ultrasound are found to have mild mitral and tricuspid regurgitation without elevated pulmonary pressures.

These cases do not belong to vulnerable groups. Severe valvular heart disease includes patients who develop heart failure or pulmonary hypertension as a result, while those with surgically treated valvular disease are considered to be at intermediate risk depending on the progression of the disease.

All patients with congenital heart disease are certainly at particularly high risk, especially those with cyanotic congenital heart disease that has been surgically corrected, as well as patients with severe cardiomyopathies.

The range of risk is even broader among patients with arrhythmias. Atrial fibrillation places patients in a high-risk category in its chronic or long-standing persistent form when it causes heart failure and increased pulmonary pressures. In contrast, paroxysmal atrial fibrillation on its own does not substantially increase the risk, with the exception of patients with a history of stroke.

By contrast, patients with supraventricular tachycardias and a low burden of premature beats (<5-10%) do not belong to vulnerable groups. Patients with severe ventricular arrhythmias, particularly those with an implanted defibrillator, practically belong to the first category of very high risk, whereas the presence of a pacemaker alone does not increase the risk beyond that associated with the underlying disease for which it was implanted or with coexisting conditions.

Special mention should also be made of patients with hypertension. Isolated, uncomplicated arterial hypertension that is well controlled with medication places patients in a vulnerable group based on recent epidemiological data from the COVID-19 pandemic, while the risk increases when severe myocardial hypertrophy, extensive vascular atherosclerosis, diabetes mellitus or a previous stroke coexist.

In recent days, reports have emerged linking antihypertensive treatment with angiotensin-converting enzyme inhibitors (ACE inhibitors) and angiotensin receptor blockers (ARBs) with an increased risk of infection and greater disease severity.

Experimental data have shown that these drugs increase levels of angiotensin-converting enzyme 2 (ACE2), which is present on the membrane of type II pneumocytes and has been implicated in facilitating the entry of COVID-19 into cells in which ACE2 is present.

At present, it has not been conclusively established whether ACE inhibitors / ARBs increase the risk of COVID-19 infection, or even whether hypertension is a true risk factor or a factor determining the severity of the disease.

In the absence of data, all international scientific organizations recommend continuing the usual use of ACE inhibitors / ARBs for the treatment of hypertension during the COVID-19 pandemic. Discontinuation is recommended only in the presence of fever, as was already indicated.

We should also refer to the effects of COVID-19 on the cardiovascular system.

On the one hand, many of the antiviral drugs being used are associated with the development of heart failure, arrhythmias and other cardiovascular abnormalities, while the direct toxic effect of the virus on the myocardium has recently been documented in the form of severe clinical or even subclinical myocarditis.

Just as we will address this pandemic, we will also need to address its subsequent consequences.