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Understanding the COVID-19 heart connection in low-resource settings

21 Jul 2020

This article is based on a paper published in Global Heart and developed through consensus by an international group of specialists, including WHF Emerging Leaders and members of the WHF Science Committee. The document aims to support WHF Members, especially those working in low-resource settings. By summarizing links between cardiovascular disease and illnesses impacting the cardiovascular system, it presents practical recommendations and may be considered a support tool for decision-making while also encouraging further research on the topic. The article is neither a clinical guideline nor a substitute for national guidelines and recommendations.

The current pandemic has put the spotlight not only on heart care but also on the particular challenges faced in low to middle-income countries: Severe Acute Respiratory Syndrome-Coronavirus-2 (SARS-CoV-2), or COVID-19, continues to claim lives in ways as diverse as the patient complications observed. The healthcare community has found itself on the frontlines of a new disease that affects and exacerbates existing conditions in those with different forms of cardiovascular disease (CVD) or with other diseases that put the heart at risk. Individuals with established CVD are more susceptible to severe COVID-19. Added to this are the challenges of delivering care in settings where critically needed medical supplies and equipment might be hard to come by. Even some high-income countries have struggled to implement rapid response and the strain is greater for countries with less solid infrastructure and fewer means to procure needed machinery and medicine.

In non-COVID-19 times, diseases affecting the heart present their own set of complications and challenges so the emerging trend of heart patients being particularly at risk from the new coronavirus is one the medical community has been hard at work to understand and manage. Diseases affecting some form of heart condition or heart function are all involved: hypertension and diabetes, acute coronary syndrome, injury to muscle tissues of the heart, (myocardial injury), heart failure, and less heard of but prevalent diseases such as rheumatic heart disease and Chagas disease. The value of knowledge-sharing cannot be overestimated and there are general as well as disease-specific measures that can be taken, even in resource-challenged settings. For example, some overarching recommendations are that:

  • COVID-19 patients need to be triaged or designated for care based on disease severity so that patients with moderate and severe disease are admitted in a separate ward or hospital depending on the available infrastructure.
  • Further, patients also need to be triaged based on underlying health risks such as hypertension, diabetes, prior cardiovascular or respiratory disease, kidney failure and cancer as part of the process to identify patients with a higher likelihood of developing a severe form of COVID-19 and implement targeted care.
  • Special attention must be given to ensuring that there are separate facilities in place for dealing with COVID-19 cardiac patients and non-COVID-19 cardiac patients including catheterization laboratories for performing invasive heart examinations.

High blood pressure (hypertension) and diabetes in COVID-19 patients

One acronym that has now become part of everyday vocabulary is ACE2, (angio-converting enzyme) found in organs such as the nose and lungs, vital for managing blood pressure, and identified as the receptor to which the virus binds for main entry. As hypertension patients often need to take medications to inhibit or block enzyme activity –ACE inhibitors (ACE-i) and ACE receptor blockers (ARB) — it was thought that medications should be stopped if they potentially favour the presence of ACE2. However, the statement by the WHF team points to various studies that have since traced our evolving understanding of the infection process, concluding that these blood pressure medications are not associated with an increased risk of in-hospital death. One analysis mentioned in the statement is from Italy’s Lombardy region that compared 6,272 people with confirmed SARS-CoV-2 infection with 30,759 controls matched by age, sex, and municipality of residence, showing that neither ACE-i nor ARBs were associated with the probability of SARS-CoV-2 infection.

Management measures include:

  • Continuing treatment with ACE-i and ARBs in patients receiving it for managing high blood pressure. This is in line with recommendations by other cardiology groups such as the American College of Cardiology (ACC) and the European Society of Cardiology (ESC).
  • Close monitoring of blood sugar fluctuations: the challenges of management due to insulin resistance is critical as diabetics are also at high-risk for COVID-19 related mortality, and in general, more vulnerable to viral infections.

Acute coronary syndrome

Cardiologists and caregivers face particular challenges when caring for patients who present with chest pain or pressure and any other symptoms of acute coronary syndrome (ACS). Because “troponins” — the substances that regulate the contractions of our heart muscle — can be high in patients with COVID-19 who are not otherwise beset by heart disease, taking clinical history, performing an electrocardiogram, and measuring troponin levels are some of the first lines of defence. ACS patients should be treated according to established guidelines, with special precautions taken with patients who have high fever and have had contact with others who have been diagnosed as COVID-19 positive.

Parameters must be defined for types of patient treatment and decisions on procedures that are urgent or can be deferred. A basic necessity is dedicated infrastructure for managing ACS in patients with COVID-19, along with crystal clear information so that suspected or diagnosed COVID-19 patients with ACS know exactly where they can access assistance. Testing for diagnosis of COVID-19 should be available at the same facilities that manage ACS patients.

Invasive procedures that involve threading instruments to vessels leading to the heart – catheterization — should be reserved for critical patients provided that the facility has systems in place for non-transmission of coronavirus during transport and treatment. Patients with stable blood circulation can have pending invasive procedures deferred.

In addition, if existing hospitals have cardiac units with more than one catheterization lab where heart images are examined, one lab could be designated for management of COVID-19 positive or suspected COVID-19 patients, with the strictest cleaning required after managing each COVID-19 patient.

Oral or surgical treatments to restore blood flow to the heart must also consider risk to medical personnel, staff availability and the number of high-dependency beds in a hospital. Along with risk from viral inflammation, heart patients also face the risk of fatty deposits in the arteries (plaque) that might rupture and medicines such as aspirin and others are a possible therapeutic way forward.

Management measures for ACS patients with COVID-19 emerge according to confirmed and suspected cases.

In confirmed cases of COVID-19:

  • Patients at low risk of heart attack (STEMI) can be treated to have blood clots dissolved (thrombolysis) while cardiac catheterization should be considered for rescue PCI.
  • Patients at high risk of heart attack would likely need primary PCI, but risks to medical staff must be considered in taking this decision, along with availability of appropriately trained lab staff.
  • Conservative management is a recommended way forward for patients at lowest risk of heart attack (NSTEMI).

In suspected COVID-19 cases infection presenting with ACS:

  • STEMI patients should receive treatment to dissolve clots (thrombolysis), as with patients who are confirmed as COVID-19 positive.
  • NSTEMI patients would not have full-blown treatment or invasive procedures but rather, more conservative management, pending test results for COVID-19. Timing is important so that results of COVID-19 tests can be integrated into planning and decision-making for control of infection.

COVID-19 patients can have a very low count in platelets that are responsible for stopping bleeding by helping cells to clot; this becomes a critical consideration in whether or not to perform surgery.

Myocardial injury

Injury to the thick inner part of heart muscle, myocardial injury, can be detected by measuring levels of proteins called troponins that help regulate heart muscle contraction. Much has been circulated about the “cytokine storms,” a term we heard from the start of the pandemic that sums up the overactive immunity processes that directly or indirectly cause some patients to succumb. Cytokines are small proteins that cells release and they marshal other cells to join the fight in inflammatory response. The detailed graphs in the WHF statement show the ways in which COVID-19 plays out in patients suffering myocardial injury and the findings that correspond to different tests such as electrocardiograms (ECG), chest x-rays and structural and functional abnormalities of the heart itself.

Management measures for myocardial injury in COVID-19 patients include:

  • Current guidelines for the treatment of viral myocarditis should be applied, including the use of standard heart failure therapies and supportive measures.
  • Prednisolone, commonly used to treat allergies, skin and blood disorders and more, has shown some benefit in a few isolated case reports, however, there is insufficient evidence to support the routine use of such steroids in these patients and may cause harm.
  • COVID-19 infection has been associated with abnormalities in blood clotting. Anticoagulation treatments to stop clotting could be beneficial though evidence to date is not based on wide analysis or beyond observational studies so expanded research and further controls would be helpful in this area.
  • Patients exhibiting structural and functional abnormalities must have an echocardiogram 1-3 months after discharge and then monitored for a minimum of six months, with heart failure therapy tailored to damage observed and recovery delays.

Heart failure and COVID-19

Case fatality rate in patients with CVD including heart failure has been reported to be as high as 10.5% compared to fatality rate of 2.3% in the general population.

Managing heart failure (HF) patients with suspected or confirmed COVID-19 begins with recognizing that respiratory infection is a common trigger of suddenly worsening symptoms– heart failure decompensation. Patients with chronic cardiac conditions, including HF, are predisposed to respiratory infections and to the complications that can occur with signs and symptoms of both cardiac and respiratory conditions overlapping. The high virulence and transmissibility of COVID-19 calls for extraordinary efforts to minimize exposure to both patients and medical staff.

Management measures include:

  • Stable patients with chronic heart failure (HF) may be followed up via telemedicine as far as possible, with elective procedures deferred. Routine flu vaccination should be considered for patients with chronic HF.
  • Patients in unstable condition coming to the healthcare facility as well as caregivers at the facility must adhere to the strictest safety measures such as adequate physical distancing, access to, and use of, personal protective equipment (PPE). Adapting infrastructure can entail sectioning off staff, wards and equipment as far as possible, and establishing patient front-facing versus non-patient-facing teams, COVID-19 positive versus negative patients wards to minimize cross-contamination, thorough disinfection of equipment used for patient evaluation, and limiting visitors but using virtual means to communicate with patients’ relatives as much as possible.
  • Clinical assessment should focus on history and physical examination, isolating patients until the diagnosis of COVID-19 is established or excluded and this may require repeated swab testing.
  • Standard investigations in the evaluation of HF patients should be considered with a number of caveats that range from conducting bedside assessments, requesting tests that affect management outcome or save lives, and with parameters for carrying out more technical, medical procedures.
  • Treatment of patients with heart failure and confirmed COVID-19 should include considerations that include, but are not limited to, continuation of medical therapies, and encouraging enrolment in clinical trials to better understand the disease and its interactions with other underlying illnesses.
  • Experimental approaches are ongoing in the management of HF and COVID-19 and include antiviral therapies though these require further study; the same is true for steroid treatment (not routinely recommended) and ongoing research into the use of anti-inflammatory agents in patients with severe COVID-19.

Further forms of heart disease adversely affecting low-resource settings

Two diseases not so often talked about outside the medical community or by those not afflicted are Rheumatic Heart Disease (RHD) and Chagas disease. They affect the poorest countries and their poorest communities, posing potential complications from COVID-19 because of their links with cardiac health and functioning. Around 33.4 million people have been estimated to be suffering from Rheumatic Fever and ensuing RHD while around 6 million people are estimated to have Chagas disease.

Rheumatic Heart disease and recommended measures during the COVID-19 pandemic

To date, there are no data on the vulnerability of patients with rheumatic heart disease (RHD) and the impact of COVID-19 infection. Usually between the age of 20 and 30 years, RHD patients may have dysfunction in the left chamber of the heart or high blood pressure in their lungs which predisposes them to complications of COVID-19.

Patient’ awareness and communications need to stress the consequences of infection and the importance of social distancing. Patients should continue their usual medication even when they experience suspicious symptoms for COVID-19 while awaiting test results. WHF launched a COVID cardiovascular disease global study (WHF-COVID) that will hopefully provide much needed data.

Chagas disease and recommended measures during the COVID-19 pandemic

Caused by a tropical parasite, Chagas disease manifests in different ways including by affecting the heart in some patients.

There is limited information available about the risk of stable asymptomatic patients, therefore those with Chagas disease should follow the same recommendations as the general population. However, those with complicated manifestations of Chagas disease are at higher risk because of the disease links with congestive heart failure and other heart ailments. A paper now underway is expected to shed more light on the inter-relationship between Chagas disease and COVID-19.

A decision should be made as to whether to suspend antiparasitic treatment and resume once recovered from COVID-19. Furthermore, three possible avenues of action correspond to the patient severity of Chagas disease and have been outlined in the WHF statement by the international collaborating team. For example, with no obvious heart difficulties or heart condition without heart failure, measures may include cautious use of medications that cause irregular heartbeat and suspending or delaying antiparasitic drugs if there are COVID-19 symptoms.

Monitoring COVID-19 and heart health

The WHF Science Committee will continue to closely monitor the evolving nature of the data on COVID-19 and its potential link with cardiovascular diseases. The information on the clinical implications of COVID-19 outbreak on cardiovascular diseases will be continually updated and panellists will be invited to join webinars so that front-line health workers can share their experiences. In addition, the WHF COVID-19 CVD global survey will provide insights necessary for clinical and policy practices, and for generating a deeper understanding of the cardiovascular conditions that can become a breeding ground for severe forms of COVID-19, and hopefully, ultimately lead to improvements in patient outcomes.