We are in challenging times, Bermuda! Never before have doctors and policy-makers had to make so many decisions with so little information. As one researcher in New York put it, we are operating in a “data-free zone.” That’s not a place the medical profession likes. But rest assured, as new information comes to light, we’ll get it to you. One thing that has become clear is that COVID-19 affects more than just the lungs.
Five Things You Should Know About COVID-19 and Your HEART
1. The Better your Heart Health, the Better your Ability to Withstand COVID-19
Persons with heart disease are especially vulnerable to contracting the novel coronavirus, and, when they do, they are at higher risk for a poor outcome. 25-50% of patients with COVID-19 have underlying medical conditions that adversely influence outcomes. In Wuhan, the case fatality rate was 6% in persons with hypertension, 7.3% in diabetics, and 10.5% in persons with established cardiovascular disease as opposed to 2.3% in the general cohort.
Think of it like this: when a 20-year-old triathlete with no underlying medical conditions contracts an infection, chances are she’ll weather it. But, for the rest of us, every decade brings subtle and sometimes not-so-subtle organ malfunctions. Because these insufficiencies accumulate slowly, we accommodate. Still, by the time you’re 70 or 80, it doesn’t take much to upset the balance. That’s why, when Granny slips, she might end up with a broken hip, followed by pneumonia, followed by kidney failure, followed by heart failure, followed by – you get the picture. COVID-19 is the kind of viral storm that can be devastating for the frail and elderly.
We know that myocarditis – heart inflammation – and heart failure can occur with COVID-19. So, it makes sense that if your heart is already compromised in some way, any additional dysfunction may have serious consequences. What can you do? Stay healthy. Heart patients should take all their medications as usual. Make sure you’re up to date with influenza and pneumococcal vaccinations. Keep up your exercise routine, but not in the gym. If you exercise outside, remain at least 6 feet from others. Eat right and get enough sleep.
2. Coronavirus Gains Entry to Cells Via the Same Receptor Some Heart Medications Target
The entry point of the coronavirus into the host cell is the angiotensin-converting enzyme (ACE2) receptor, which is present on airway epithelial cells. It’s also present on heart muscle cells. Many patients take high blood pressure or heart failure medications called angiotensin-converting enzyme inhibitors (ACEI) or angiotensin receptor blockers (ARBs). These medications target these same receptors. Typical examples are enalapril, lisinopril, losartan, candesartan, and valsartan. These ACE2 receptors may “up-regulate” in persons on these medications. This means additional receptors may develop or activate on their lung and heart muscle cells. One concern is that more receptors may mean more entry points for the virus. Others speculate that since these drugs block or alter these receptors in some way, they may confer a protective effect. At this point, we’re not sure. Remember, in most cases, these drugs are prescribed for other potentially life-threatening (non-COVID-19) conditions. We recommend staying on these essential medications.
3. Coronavirus Starts in the Lungs but Also Affects the Heart
A study published last week in JAMA Cardiology revealed that amongst a group of hospitalized COVID-19 patients in Wuhan, 19.7% suffered cardiac injury – of those, 51% died compared to a 4.5% death rate in those without cardiac injury. At this point, we don’t know whether the damage is due to direct invasion of heart muscle by the virus (in which case antiviral medications may help) or whether it’s the hyped-up immune response (in which case immunosuppressive drugs may help). As you can imagine, either effect is worsened by low oxygen levels due to lung involvement. Coronaviruses also activate inflammatory mediators that can destabilize arterial plaques resulting in heart attacks.
I know, it all sounds grim. What can you do? Once again, it’s essential to take all your medications as usual. Statins have plaque-stabilizing properties that may be helpful right now, and antiplatelet agents like aspirin and clopidogrel prevent clots that form in the wake of plaque disruption.
4. Some Proposed Treatments for COVID-19 have Cardiac Side Effects
Hydroxychloroquine is an antimalarial drug, also used as an immunosuppressive agent in diseases like lupus and rheumatoid arthritis. It might prevent coronavirus from attaching to and entering cells. Hydroxychloroquine can also affect the electrical properties of the heart. The “QT interval” is an indicator of the ability of the heart to recharge after each beat, and we can measure it on your ECG. Hydroxychloroquine increases the QT interval and can cause arrhythmias that result in sudden death. You may have already heard about the Arizona man who died after ingesting a related chemical, chloroquine, a fish tank cleaner, purportedly to ward off COVID-19. Azithromycin is an antibiotic sometimes used with hydroxychloroquine. Its mechanism of action in this condition is unclear (since COVID-19 is not a bacterium), but it, too, can cause QT abnormalities. In anticipation of hydroxychloroquine and azithromycin becoming more widely used, last week the FDA gave emergency approval to the popular Kardia app (see Annals of Cardiology No. 24: Apples and Chips), for at-home QT interval measurement and monitoring.
Once a person contracts COVID-19, the treatment is supportive. That means oxygen, ventilators if needed, blood pressure support, antibiotics if there are superimposed bacterial infections, and generalized organ support. Antiviral agents and immunosuppressives are being tested or tried in specific cases. For some, ECMO is used – it’s a life support machine that replaces the function of the heart and lungs by pumping the patient’s blood externally into an artificial oxygenator and then back into the body.
It sounds awful, and it can be awful. Thankfully, many COVID-19 cases are mild and may feel like a cold or the flu. Regardless, right now, the #1 treatment for COVID-19 is prevention. Don’t get it. I don’t have to re-iterate all the physical distancing precautions we should be practicing.
5. Long Term Social Isolation is not Healthy for the Heart
Social isolation is associated with a higher risk of heart attacks, stroke, and death. It’s just not healthy for a heart, especially in the long term. That’s one reason terminology is changing to the preferred “physical isolation” measures rather than “social isolation.” Let’s hope that our current isolation – so vital at the moment – won’t be necessary for prolonged periods. In the meantime, thank goodness for Facetime, WhatsApp, Zoom, Skype, and oh yes, the old-fashioned telephone.
For many, loss of social interaction is compounded by loss of routine, loss of opportunity, loss of experiences (welcome home, students), and loss of income. For Bermuda, let’s pray we don’t see too much loss of loved ones.
These are difficult and unpredictable times. But these temporary challenges are not insurmountable. Live each day to the fullest, within the public health restrictions imposed. Develop a routine for the new norm. Exercise every day. Eat right. Get enough sleep. Enjoy your family. Stay connected via phone and social media. Spend some time outside (yes, 6 feet away from others). And, hard as it may be, find something to laugh about. With that in mind, this appeared on my Twitter feed, originally posted by @MumbaiPolice! Whether you believe in astrology or not, you have to admit this prediction is spot on.
Stay safe, Bermuda.
For more news on the latest developments in cardiology, visit www.ShaneMarshallMD.com, subscribe to the free newsletter The Annals of Cardiology, and follow Dr. Marshall on Twitter @ShaneMarshallMD
