COVID-19 pandemic may impact CV health despite infection status in patients
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COVID-19 not only affects the CV health of infected patients, but it also affects the CV care of patients even in the absence of infection, according to two presentations at the virtual Heart in Diabetes Conference.
“This is a field that’s rapidly moving,” Mansoor Husain, MD, professor of medicine at University of Toronto and executive director of the Ted Rogers Centre for Heart Research in Toronto, said during the presentation. “Our understanding of COVID-19 remains quite limited. Experience and expertise are in short supply, of short duration and fragmented.”
Husain said that although there is a need to share information about COVID-19 as rapidly as possible, this expedited process for publication can lead to issues including less vigorous peer review and varying perspectives from the medicine, science and business fields as well as others.
CVD in COVID-19
Symptoms common in patients with COVID-19 include fever, fatigue and nonspecific respiratory symptoms. Knowledge has emerged related to symptomatic COVID-19, as we recognize that loss of appetite, loss of taste or hyposmia as dominant symptoms.
“What’s interesting is, is while symptomatic infections are of greatest relevance to acute health, with the current burden being about 4% of all cases need hospitalization, what we don’t understand is what’s the long-term health implications of symptomatic infection,” Husain said.
We also do not understand the implications of asymptomatic infection, as there are a lot of uncertainties in that area related to long-term health, epidemiology and its relevance to health systems, Husain added.
Mortality factors
Several recent studies have aimed to determine the factors associated with mortality from COVID-19. In a study assessing the OpenSAFELY platform published in Nature, COVID-19 deaths were associated with advancing age, male sex, obesity with a BMI greater than 40 kg/m2, deprivation, diabetes with hemoglobin A1c greater than 7.5%, reduced kidney function with an estimated glomerular filtration rate less than 30 mL/min/1.73m2, CVD, chronic obstructive pulmonary disease and Black and South Asian ethnicity.
In a study published in The Lancet of patients from Wuhan, China, when comparing those who survived and with those who did not, there were differences in age, male sex, hypertension, diabetes, CAD and more severe presentations of COVID-19. These differences were present even though the disease course of patients who survived vs. those who died were nearly the same, Husain said.
He added that a clear indication of poor prognosis in patients with COVID-19 was elevations in cardiac troponin and D-dimer, in addition to persistent lymphopenia.
“This was our first clue,” Husain said.
A study published in JAMA Cardiology found that of 416 patients from Wuhan with COVID-19, 19.7% had cardiac injury defined by troponin elevation. The mortality rate was 50% in those with cardiac injury and much less in those without it. Researchers also found that typical timing of death, approximately 2 weeks after symptom onset and 1 week after hospitalization, “did not differ between those with or without cardiac injury,” Husain said.
Another paper published in JAMA Cardiology found that when patients had neither a history of CVD nor troponin elevation, the mortality rate was 7%. This increased by twofold in patients with CVD and by fivefold in those with cardiac injury. The mortality rate increased by 10-fold in patients with both CVD and cardiac injury.
“This tells us something,” Husain said. “With a very simple clinical history and a single biomarker, you can identify people at greatest risk.”
COVID-19 can present in multiple ways in the heart including myocarditis, myocardial injury, ACS, arrhythmias, stroke, HF, cardiogenic shock, venous thromboembolism or pulmonary embolism,” he said.
The ATTACC trial is currently underway, which is testing the hypothesis of whether therapeutic anticoagulation can reduce mortality and/or the need for mechanical ventilation in patients hospitalized with COVID-19. The SEMPATICO trial will assess whether the GLP-1 receptor agonist semaglutide (Ozempic, Novo Nordisk) can reduce the composite primary outcome of death or the need for cardiorespiratory support in patients with COVID-19.
“The take-home message [is] identify COVID-19 patients that have injury, consider them for more aggressive treatment, prepare to manage their dysfunction and arrhythmia, use the antivirals we know [like] remdesivir (Gilead Sciences), use the anti-inflammatory we know [like] dexamethasone and we hope to have data to validate antithrombotic use and perhaps other cardioprotective agents,” Husain said.
Impact on CV care, prevention
It was originally thought that SARS-CoV-2 was going to primarily be a respiratory virus, but manifestations within the CV system became apparent quickly, Laurence S. Sperling, MD, FACC, FACP, FAHA, FASPC, Katz Professor in Preventive Cardiology, founder of the Emory Center for Heart Disease Prevention and professor of global health at Emory University, executive director of Million Hearts and past president of the American Society for Preventive Cardiology, said during his presentation at the meeting.
Patients who are severely ill have an intense acute inflammatory response and a cytokine storm, in addition to effects on endothelial function, platelet function and procoagulant activity, which put them at risk for CV events including thromboembolic events, MI, stunned myocardium and myocarditis, Sperling said.
“We do know that those living with cardiovascular diseases appear to be at greater risk for this intersection,” he said.
The COVID-19 pandemic has affected the number of patients who go to the ED for CV events. According to CDC data, 10 weeks after COVID-19 was declared a national emergency, there were decreases in ED visits for MI, stroke and uncontrolled high blood sugar. More data show that hospitalizations, ICU admissions and deaths increased in patients with COVID-19 with underlying serious health conditions including CVD, diabetes and chronic lung disease.
The pandemic also confers delay in CV care and diabetes care, and interrupts inpatient care and preventive care, Sperling said.
A clinical practice statement from the American Society of Preventive Cardiology published in the American Journal of Preventive Cardiology provides several recommendations for patient visits during the COVID-19 pandemic, including using telehealth, not deferring patient visits, asking about symptoms at each visit, encouraging the use of EMS or a visit to the ED for concerning symptoms and using the full care team to enhance patient care.
The American Heart Association has raised the question of the long-term effects of COVID-19. While not all the answers are known, people with heart disease and diabetes are at increased risk; staying at home can impact unhealthy habits; and clinicians must focus more on patients with the greatest need such as those in vulnerable populations, Sperling said.
“Right now, we are learning about the vulnerable populations in this pandemic — families that cannot access the social support that has been very critical to their health and disease prevention,” he said.
Sperling said he hopes the future includes the acceleration of new care models such as telehealth; decreased use of ineffective, low-value care; furthering of the volume-to-value transformation, and rapid movement to further health care integration and consolidation.
Although there are many challenges related to social determinants of health, cardiologists and health care professionals need to think differently to address these issues compared with traditional CV risk factors.
“As clinicians and health care systems, traditional cardiovascular risk factors tend to be our major area of focus, but about 80% of health and disease is determined outside of our traditional health care venues,” Sperling said.
In particular, clinicians should focus on poor access to care and healthy foods, in addition to behavioral factors, psychosocial factors and environmental factors.
There is also a need for comprehensive and complementary prevention programs that focus on where we live, learn, work and play. This involves integration of traditional health care with public and global health, industry and workplace, schools and churches, the media and government.
Precision medicine may also play a role after the COVID-19 pandemic, which emphasizes the importance of providing the right treatment to the right patient at the right time. This can also impact precision public health, which focuses on an entire population.
CV and cardiometabolic pandemics
The COVID-19 pandemic, Sperling said, is not the only pandemic currently occurring; there are also CV and cardiometabolic pandemics.
“As we learn about addressing pandemics, we need to realize that the chronic disease pandemics can be thought of in a similar fashion,” Sperling said. “We need to identify vectors and complex causes, but also identify barriers, roadblocks and factors that propagate these epidemics, with the end goals of control, elimination and, someday, hopefully eradication.”
For the latest news on COVID-19 including case counts, information about the global public health response and emerging research, please visit the COVID-19 Resource Center on Healio.
References:
- Guo T, et al. JAMA Cardiol. 2020;doi:10.1001/jamacardio.2020.1017.
- Khera A, et al. Am J Prev Cardiol. 2020;doi:10.1016/j.ajpc.2020.100009.
- Shi S, et al. JAMA Cardiol. 2020;doi:10.1001/jamacardio.2020.0950.
- Williamson EJ, et al. Nature. 2020;doi:10.1038/s41586-020-2521-4.
- Zhou F, et al. Lancet. 2020;doi:10.1016/ S0140-6736(20)30566-3.
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Husain M.
Sperling LS. COVID-19 in DM and CVD. Both presented at: Heart in Diabetes CME Conference; August 21-24, 2020 (virtual meeting).
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