The COVID-19 Pandemic and its implications for people with Heart Disease

-Dr. Pranab Bhattacharyya |

The coronavirus disease 2019 (COVID-19) outbreak has been classified as a pandemic last week by the World Health Organization as the upsurgeof this disease now extends across the globe. Communities world over are joining hands to limit its spread. Schools and colleges are closing, conferences andpublic events are being canceled, even sporting events have either been canceled or postponed. The COVID-19 is a quickly evolving public health emergency.Amongst this pandemonium, people with pre-existing heart disease are certainly concerned about their health and well-being.

The new virus was first reported late December in China. As of March 11, it had affected more than 100 countries, including the United States. The main symptoms of the disease are Fever, Cough and Shortness of breath. For most people (80% of cases) the illness is mild. However, the virus can cause severe illness with complications such as pneumonia, organ failure, and death.According to the Centers for Disease Control and Prevention (CDC), those who have a higher chance of getting very sick include people who are older than 60 years (with people 80 years and older being at  highest risk), those who have heart disease and lung disease. The overall case fatality rate of COVID-19 is low at 2.3%. However, case fatality rates for comorbid patients are higher than the average population(Cancer 5.6%, Hypertension 6.0%, Chronic respiratory disease 6.3%, Diabetes  7.3% and Cardiovascular disease 10.5% ).

Acute cardiac complications of COVID-19 may include arrhythmia (abnormal heart rhythm), heart failure, myocardial infarction (heart attack), myocarditis and cardiac arrest. Current reporting does not yet describe prevalence of cardiac complications in those without pre-existing heart disease versus those with existing cardiac conditions. However, it must be appreciated that cardiac complications of COVID-19 are approximately commensurate with SARS, MERS, and influenza analogs.

For patients with underlying cardiovascular conditions there are several implications of COVID-19 pandemic. Patients with underlying cardiovascular disease are at higher risk of contracting COVID-19 and have a worse outcome. It is reasonable to advise heart patients of the potential increased risk and to encourage additional, reasonable precautions. In areas with active COVID-19 outbreaks, it is recomendedto substitute telephonic consultation for in-person routine visits for stable heart patients to avoid possible hospital acquired COVID-19 infection. In patients with acute myocardial infarction (heart attack) the classic symptoms and presentation may be overshadowed in the context of COVID-19, resulting in under diagnosis. For patients with heart failure or volume overload conditions, intravenous fluid administration for viral infection should be used cautiously and carefully monitored. General immunological health remains important, including eating well, sleeping and managing stress.

Another area of concern is regarding the continuation of blood pressure medicines especially those who are taking ACE inhibitors (common medications in this group include ramipril, perindopril, enalapril, lisinopril) and ARB’s (losartan, telmisartan, olmesartan) because of the speculation that these medicines increase the chances of severe Covid-19 infections. In this context expert groups from the medical profession have reviewed the scientific information and they agree that there is a lack of evidence to support this speculation. As these drugs are very effective for heart failure, and to control high blood pressure and to help prevent a heart attack or stroke, it is really important to continue to take them as prescribed.

Cardiac-specific preparedness is important to effectively tackle this COVID-19 pandemic – to develop protocols for the diagnosis, triage, isolation, and management of COVID-19 patients with cardiovascular complications and/or cardiovascular patients with COVID-19 and to don personal protective equipment (PPE) by cardiovascular care team members. Apart from these, specific protocols should be developed for the management of acute myocardial infarction (heart attack) in the context of a COVID-19 outbreak. Particular emphasis should be laid to develop protocol to limit cardiac cath lab use (use of medications instead of immediate angioplasty), manpower inside the cath lab, enhanced personal protection and adequate post procedure sterilization.In extreme circumstances, a need may arise to assess the risk benefit ratio of acute MI intervention (primary angioplasty)against hospital acquired infection risk. This is because of the limited data on primary angioplasty benefit for type-2-MI from acute viral illness.

Although what we know is changing rapidly, here are important take home message for patients with heart diseases and their families in the background of this COVID-19 pandemic situation.Adoption of adequate defense against infection – thorough hand washing with soap and water for at least 20 seconds, covering of mouth and nose while coughing or sneezing, avoid touching eyes, nose and mouth, cleaning surfaces touched often like door knobs, handles, car steering wheels or light switches with a disinfectant. In addition, it is equally important to practice social distancing by avoiding large gatherings and limiting travel. Wearing of surgical mask is recommended when in the hospital and N95 while in isolation rooms. Apart from these, continuing cardiac medicines as prescribed, avoid going to hospital for routine checkup and instead seek telephonic opinion and keeping up healthy habits including healthy diet, exercise, enough sleep, and stress management will go a long way to ensure good health and well-being of people with heart disease during these troubled times.

 (the author is Professor of Cardiology, Gauhati Medical College and Fellow of Cardiological Society of India, American College of Cardiology, Society for Cardiovascular Angiography and Interventions, USA and European Society of Cardiology)