COVID-19: Providing ongoing care to patients with cardiovascular disease in a pandemic
We are living through a pandemic! A battle: humanity against a bug…
The world is facing unprecedented challenges as a result of a bug called COVID-19 (Sars-CoV-2) that has literally gone “viral” across the globe affecting >250K individuals in 183/195 countries, claiming >10,000 lives in a short period of time (as of 15:00 20/3/2020).
COVID-19 has disrupted our daily lives, schools/universities shut down, cities/countries in lock down, travel ban, large gatherings including major cardiac scientific society meetings now cancelled, with immense pressure on our health care services and it is heart breaking to witness the devastation caused!
But life goes on and as cardiovascular health professionals how do we continue to care for our patients? It appears we will be in this pandemic for a little while longer to say the least from now…
How do we get through this and provide as best care to our patients as possible?
As we begin to learn a lot about the new virus, COVID-19 or Corona virus, it appears the disease will be mild in most cases (~80%). However given the fact that our ICUs are filling up rapidly with previously healthy young people on ventilators (~5% of COVID-19 infected patients needing ITU care), it is indeed without a doubt a serious threat!
Cardiovascular disease remains world’s biggest killer. COVID-19 seems to escalate the risk in our patients with heart disease. Importantly, it seems the older patients with a mean age of 81 years with co-morbidities such as cardiovascular disease, diabetes, hypertension are at the highest risk of mortality as such (1), (2). Approximately 70% of over 70 years of age have died as a result of the viral infection. Increasing odds of in-hospital death was associated with older age (odds ratio 1·10, 95% CI 1·03–1·17, per year increase; p=0·0043)1. A recent review sheds light on Cardiovascular Considerations for Patients, Health Care Workers, and Health Systems During the Coronavirus Disease 2019 (COVID-19) Pandemic (3).
Given the virus spreads from person to person (4), it is vital everyone (including those infected, those caring for them, those around them) follow simple procedures such as hand washing, catch it-bin it-kill it procedures and physical/social distancing to contain the virus. The incubation period is on average 5 days for Sars-CoV-2.
Managing myocardial infarction in the COVID-19 pandemic
Whilst the above approaches (social/physical distancing) are feasible strategies for those with chronic heart conditions, patients needing emergency medical attention for example in the setting of STEMI will need to be admitted for emergency care. We all know that primary percutaneous coronary intervention (PPCI) is the gold standard for STEMI with 30-day mortality for those that were treated with PPCI is ~6%5 much lower than those treated with thrombolysis (6). However we are in the midst of a crisis with high chances of contracting the virus, there is an immediate need for health care professionals to develop/follow their own institutional infection prevention control protection measures, guidelines in the care of such patients.
From what we see, from what colleagues share their experiences on social media, it is not always possible to know who is infected and who is not. Some patients with COVID-19 seem to present as STEMI which only gets picked up after a normal diagnostic angiography procedure. With rapid evolution and spread of the disease, this raises the question if all frontline staff treating these patients should be protected. The obvious answer appears ‘Yes’ in the context of shortages of such protective equipment for staff. We did manage heart attacks with thrombolysis in the past but of course this has its own disadvantages of excess bleeding, less reperfusion rates, prolonged hospitalisation etc., which is not what we want right now. We really are in an uncharted territory with an immediate need for innovative/concerted approaches to tackle the situation…
The mortality rate post PCI in the setting of NSTEMI is <2% at 30-days (5). In these challenging times it might also be appropriate to determine if patients stabilised on medical therapy could be discharged early and reserve interventional approaches to those unstable patients with ongoing symptoms despite optimal medical therapy.
Out-patient clinics and elective procedures
Given physical/social distancing is being discussed as a potential way of mitigating the spread of the virus with delaying the peak in the community, it is appropriate to explore alternate ways of interacting with these patients such as telephone or skype or virtual clinics and avoiding hospital visits and postponing elective procedures. The latter approach has already been implemented in many countries including the UK.
COVID-19 is known to adhere to the Angiotensin Converting Enzyme 2 (ACE2) receptors7 and thus there are concerns regarding the continued treatment with ACEI/ARBs in patients already taking these drugs. To date we do not know if these medications cause harm in infected patients. Until such evidence emergences, it is prudent to continue cardiovascular therapy as advised by doctors.
Cardiovascular Research Studies
Whilst efforts during this pandemic should be focussed on treating infected patients needing urgent/emergent medical care, a prudent approach would be to evaluate the essential need for a particular research study in the context of local strain/pressures on resources (staff, logistics and costs etc.,). National authorities (8), (9) already provide some guidance on how to deal with clinical research studies which are reviewed at the institutional level evaluating the pros and cons of ongoing research conduct and any potential modifications to research conduct or suspension of ongoing studies. Worldwide the priority is now to conduct research studies looking at COVID-19. Given the impact of COVID-19 on the cardiovascular system as always as CV healthcare professionals and researchers we will play an important role in this unexpected problem/crisis we are all facing currently.
When humanity is tested…
As we live through these unpresented days in our lives and in our history, with a lot unknown, rapidly learning as we go along, we try our very best to support our fellow human beings (patients, colleagues, public, authorities) by being considerate, kind, compassionate, looking after ourselves and each other and of course not forgetting #handwashing and #social distancing, given we are all in this together in our battle/war against COVID-19!
As healthcare professionals looking after such patients it goes without saying that now than ever it is absolutely crucial we take care of our own selves, the workforce, and our colleagues.
As we always do, we will get through this and we hope that this too shall pass…
References
- Zhou F, Yu T, Du R, Fan G, Liu Y, Liu Z, Xiang J, Wang Y, Song B, Gu X, Guan L, Wei Y, Li H, Wu X, Xu J, Tu S, Zhang Y, Chen H and Cao B. Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study. The Lancet.
- Remuzzi A and Remuzzi G. COVID-19 and Italy: what next? The Lancet.
- Driggin E, Madhavan MV, Bikdeli B, Chuich T, Laracy J, Bondi-Zoccai G, Brown TS, Nigoghossian CD, Zidar DA, Haythe J, Brodie D, Beckman JA, Kirtane AJ, Stone GW, Krumholz HM and Parikh SA. Cardiovascular Considerations for Patients, Health Care Workers, and Health Systems During the Coronavirus Disease 2019 (COVID-19) Pandemic. Journal of the American College of Cardiology. 2020:27204.
- Ghinai I, McPherson TD, Hunter JC, Kirking HL, Christiansen D, Joshi K, Rubin R, Morales-Estrada S, Black SR, Pacilli M, Fricchione MJ, Chugh RK, Walblay KA, Ahmed NS, Stoecker WC, Hasan NF, Burdsall DP, Reese HE, Wallace M, Wang C, Moeller D, Korpics J, Novosad SA, Benowitz I, Jacobs MW, Dasari VS, Patel MT, Kauerauf J, Charles EM, Ezike NO, Chu V, Midgley CM, Rolfes MA, Gerber SI, Lu X, Lindstrom S, Verani JR and Layden JE. First known person-to-person transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in the USA. The Lancet.
- Kunadian V, Qiu W, Lagerqvist B, Johnston N, Sinclair H, Tan Y, Ludman P, James S and Sarno G. Gender Differences in Outcomes and Predictors of All-Cause Mortality After Percutaneous Coronary Intervention (Data from United Kingdom and Sweden). The American journal of cardiology. 2017;119:210-216.
- Keeley EC, Boura JA and Grines CL. Primary angioplasty versus intravenous thrombolytic therapy for acute myocardial infarction: a quantitative review of 23 randomised trials. Lancet (London, England). 2003;361:13-20.
- Zheng Y-Y, Ma Y-T, Zhang J-Y and Xie X. COVID-19 and the cardiovascular system. Nature Reviews Cardiology. 2020.
- https://mhrainspectorate.blog.gov.uk/2020/03/12/advice-for-management-of-clinical-trials-in-relation-to-coronavirus/ . 2020.
- https://www.hra.nhs.uk/planning-and-improving-research/policies-standards-legislation/covid-19-guidance-sponsors-sites-and-researchers/ . 2020.
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