Thursday

April 2nd, 2020

Wellness

Cardiac issues? What you need to know now about Covid-19

 Dr. Haider J. Warraich

By Dr. Haider J. Warraich The Washington Post

Published March 23, 2020

Cardiac issues? What you need to know  now about Covid-19
As the novel coronavirus spreads around the world, it primarily sickens people by affecting their lungs. But it is now becoming clear that the finishing blow for people who don't survive might be to the heart. For the more than 120 million American adults living with heart disease, including many of my patients, these are understandably distressing times.

The experience of intensive care doctors managing covid-19 points to a dangerous turn many patients take. While the syndrome initially develops slowly, in some vulnerable people it can accelerate quickly, causing respiratory arrest and requiring artificial breathing with mechanical ventilators. Yet the patients who end up dying, says James Town, an intensive care doctor who has been in the thick of if in Seattle, actually die of cardiac rather than respiratory failure.

"A few of the patients we've had have also developed pretty profound cardiogenic shock, and those are the ones who have passed away so far," he told NPR's Lulu Garcia-Navarro. This cardiogenic shock was "more dramatic than just the respiratory failure that we kind of expected to see."

The Center for Disease Control and Prevention lists older adults and people with heart disease, lung disease and diabetes, as the main high risk groups in this pandemic. Data published in the journal Lancet from patients admitted to hospitals in Wuhan with covid-19 shows that while not all patients have damage to the heart, it can be an ominous sign in those that do: evidence of cardiac injury was noted in 59% of those who died vs. only 1% of survivors.

Severe covid-19 infection can cause massive inflammation throughout the body, and if it affects the heart, the consequences can be dire. Fast, abnormal heart rhythms were responsible for 44% of Wuhan patients being transferred to the intensive care unit.

Laboratory tests of human proteins called troponins, which can indicate damage to heart muscle, can indicate which patients will probably do poorly.

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While menacing heart complications usually occur late in the course of most patients with covid-19, some rare patients are presenting initially with extensive inflammation of the heart.

The CDC recommends that people at high risk, such as those with heart disease, take all the same precautions that apply to everyone right now - stay at home, avoid crowds, clean your hands and your surroundings often - but they should do some additional things:

• Make sure they and their caregivers have a phone number to access their medical team. For those who don't have an established relationship with a heart care team, they should call their primary care physician or hospital or public health department hotline.

• Stock up on any medications, and if they're running short, call the clinic or get your doctor to have refills called or routed in to a pharmacy.

• Make sure that basic medical equipment, such as a thermometer, a blood pressure machine and a weighing scale, is accessible.

• Monitor your body closely for signs and symptoms common in covid-19, including temperatures above 100 degrees, difficult breathing, coughing. A runny nose is much less common and more likely a sign of a cold or allergies.

• Let caregivers and a medical team known about these symptoms - they do not necessarily require going to the emergency room. Danger signs include worsening shortness of breath, chest pain, confusion or drowsiness and bluish lips. If any of these symptoms develop, call 911 or go to the nearest emergency room.

Concern has been raised about some common medications used by patients for hypertension or heart disease called angiotensin-converting-enzyme inhibitors, or ACE inhibitors (with names ending in -pril, such as lisinopril), and angiotensin II receptor blockers (ARBs, with names ending in -sartan, such as valsartan).

The reason for this concern is that the novel coronavirus attaches to ACE2 proteins on the surface of cells in the airway and lungs, allowing it to then hijack the cell and subsequently use its machinery to make millions of virus copies. In animal studies, ACE inhibitors and ARBs have been shown to increase the expression of ACE2 proteins.

That finding has lead some to speculate that the medications make patients with heart disease more vulnerable to covid-19 complications. But animal studies often do not translate into humans. And there is also some evidence that the medications might be protective of the lungs, with people taking these drugs having reduced lung injury when infected with other viruses.

Given that there is no evidence of harm in covid-19 patients and mountains of evidence about the lifesaving benefit in patients with hypertension and heart disease, the major cardiovascular organizations in the United States and Europe have said these medications should be continued.

On the other hand, use of over-the-counter nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, probably should be minimized. The French government recently issued a warning about their use being associated with worse outcomes in all people. Heart patients who take blood thinners are generally advised to avoid such NSAIDs, since they can increase bleeding risk and may cause kidney damage. I have suggested to my patients that they either switch to acetaminophen (such as Tylenol), which is gentler on the kidneys or use the minimum dose of NSAID until we have better information.


Many hospitals are moving to cancel nonurgent procedures, tests and clinic visits. Most nonurgent clinic visits are being deferred or instead are being performed over the phone or using video conferencing. This move will both reduce patients' and their medical team's risk of acquiring the virus and will help conserve resources in the event of the health system being overrun with covid-19.

Virtual visits are most effective when patients have a family member around to coordinate plans, have their pills on hand to confirm what they are taking, and have access to basic information such as their weight and blood pressure, if they have the equipment.

For patients with heart disease, virtual connectedness to their health-care staff can be a lifesaver. A similar connection to family and friends can help provide another layer of protection. I've been sharing my cellphone numberwith patients and encourage other doctors of high risk patients to do the same.

And even as we focus on this pandemic, It's worth noting that other diseases are not slowing down. Heart disease remains the leading killer of people in the United States and around the world, and it is not ready to give up that distinction any time soon. With the right precautions and with heightened vigilance, we can try to ensure that covid-19 doesn't help increase that toll.

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Warraich is a cardiologist at the VA Boston Healthcare System, Brigham and Women's Hospital and Harvard Medical School. He is also author of "State of the Heart: Exploring the History, Science, and Future of Cardiac Disease."

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