The Evolving Face of Cardiovascular Care in the Peri-pandemic Era

Ahaana Singh, Kemar J. Brown, & Jagmeet P. Singh

Abstract

COVID-19 can affect the heart in many ways, causing heart rhythm disorders, acute heart attacks, heart failure, and sudden cardiac death. Although the virus is known to have a predilection for those with risk factors for cardiovascular disease, it can adversely impact every major organ system in the body. The long-term sequelae of the disease are yet to be appreciated, highlighting the need for post-COVID surveillance and multidisciplinary clinics. Notably, COVID-19 has resulted in higher cardiovascular events and death rates in racial minorities and those of lower socioeconomic status. The uptick of telehealth and digital strategies has enabled the provision of clinical care in this period of social distancing. Regrettably, this has deepened the digital divide and further accentuated the preexisting health inequities. We have an obligation to take advantage of this pandemic to correct inequalities and improve the overall cardiovascular health of our community.

We are currently in the midst of another COVID-19 surge, with case positivity rising exponentially. To date, millions of people across the globe have been infected and survived the SARS-CoV-2 virus. And yet, nearly 9 months into the pandemic, we are still grappling with countless uncertainties — clinically and societally. Understanding the biological and clinical nature of the virus has been critical to patient care. Specifically, this has provided us insights into i) the care of patients with comorbidities and ii) a platform to provide comprehensive care in our socially distanced world.

It would be remiss not to note that the impact of this disease goes beyond its attack on the human body; this disease has made its way into the crevices of our health system. COVID-19 has exposed and further amplified the longstanding inequities within the US health system. And while we continue to manage the clinical havoc created by the virus, it is also essential to give due consideration to improving inequalities in care.

Heart Health and COVID-19

The last few months have taught us that COVID-19 patients with underlying comorbidities such as hypertension, diabetes, coronary heart disease, and heart failure are at a higher risk for death and complications. ^1,2 The virus can afflict those with preexisting heart disease and cause a flare up of the underlying cardiac condition. This can be caused directly, through the cardiotoxic effect of the virus on the heart cells, or indirectly, through reduced oxygen levels or an accelerated immune response that can accompany the sickness. ² The latter has been shown to be related to the release of inflammatory cytokines resulting in myocarditis (inflammation of the heart), heart failure, heart rhythm disturbances, or an acute heart attack. ²

At the other end of the spectrum, the virus may infect a previously healthy patient and lead to heart failure, a heart attack, or even a life-threatening heart rhythm disturbance as the initial mode of presentation. The illness is also associated with the development of clots in the lungs, brain, and limbs. Each of these can have immediate devastating consequences and lasting residual problems such as oxygen-dependence and paralysis.

Notably, a matter of great concern has been the occurrence of life-threatening arrhythmias, leading to cardiac arrests in the ICU and outside of the hospital. ³ We know from the New York and the Italian (Lombardi) experiences that the out-of-hospital incidence of sudden deaths was up three-fold in the first two months of the pandemic. ^4,5 In the hospital setting, we have seen that patients with evidence of myocardial injury (evidenced by an elevation of cardiac enzymes) are associated with a much higher death rate. The long-term recovery in patients who have a significant immunological response is still unclear. Several patients have been noted to have continued inflammation of the heart along with residual lung disease several weeks to months post-discharge from the hospital. In fact, in many patients with prior cardiac disease, it becomes challenging to discern the contributing impact of the residual lung disease versus the underlying cardiac condition to their persistent symptoms. Also noteworthy is that cardiac imaging in asymptomatic and mildly symptomatic patients (including athletes) has shown the occurrence of persistent myocarditis and myocardial injury. ⁶ Whether this increases the propensity to sudden cardiac arrest or other forms of cardiac illness remains unclear. Although our understanding of the disease has grown, treatment continues to be largely supportive. The use of steroids has proven beneficial only amongst symptomatic hospitalized patients with an exaggerated immune response, and the recently approved anti-viral Remdesivir has helped to reduce hospital stay. Most other treatments have proven either equivocal or detrimental.

Inequitable Care

COVID aside, cardiovascular disease has been the number one cause of mortality across the globe for several years. In the US, in particular, Black individuals are over 30 percent more likely to die from heart disease and twice as likely to have a stroke compared to other groups. ⁷ In the face of the pandemic, disparities in our healthcare system have been considerably emphasized. In fact, the CDC reports that Black and Brown people are experiencing significantly higher rates of diagnosis and hospitalization with COVID-19. Moreover, Black Americans face a death rate that is over 2 times higher than that of White Americans.8 And despite making up around 20% of US counties, disproportionately Black communities have been faced with over 50% of COVID cases nationwide. ⁹ Access to care seems to be a large part of the problem, as studies show that more than half of the uninsured population in the US are comprised of African Americans, non-White Hispanics and other racial minorities. But beyond access, structural discrepancies in living standards, education, and social inclusion are critical contributors to this widening divide. ¹⁰ Controlling and overcoming this virus will not only require therapeutics and preventive strategies, but also structural changes within our health care system that help us overcome these inequities.

Digital Solutions: Deepening the Divide?

Physical distancing has become a primary strategy to control spread of the virus, and patients and physicians alike have rapidly gravitated towards virtual strategies. With this has come an increased recognition of the importance of wearables and implantables that can help make a virtual visit a sufficient replacement for an in-person interaction. ^11,12 And as we get more comfortable in the confines of our homes, the virtual care experience is expanding to multidisciplinary clinic visits, where the same tele-visit has subspecialists ‘zooming-in’ to provide a one-stop shop. Because of the complexity of the post-COVID patient with overlapping pulmonary, cardiac, neurological, renal, and vascular diseases, it is now possible for everyone to connect at the same time (at the same visit) through virtual platforms. Such multidisciplinary assessments will be essential for the hundreds of thousands of survivors with lingering symptoms or complications. Moreover, such comprehensive care at the touch of a button could alter our health system entirely.

Nonetheless, building digital health solutions without increasing accessibility to technology may worsen health inequities. The unfortunate truth is that the advent of digital approaches has only deepened the divide. Marginalized communities, who have been unevenly assaulted by COVID-19 and cardiovascular disease, must be prioritized as we build and implement new virtual solutions. This will ultimately help to improve long-term health outcomes across all communities.

Can we do it?

The intersection between technology and healthcare has never been more profound. Neither telehealth nor advanced sensors for disease management are new concepts, but these technologies haven’t had the opportunity to be developed to their potential. Innovators have historically been deterred by clinicians’ reticence towards the adoption of these innovations into clinical practice. We know that establishing new tools, systems, and processes take time in our healthcare system, but the pandemic has changed that timeline.

As we look towards the future, herein lies an opportunity to carve out resilient healthcare initiatives — through the expansion of telehealth, sensors, and remote monitoring, we have the power to provide patients with comprehensive care in the safety of their own homes. It is our responsibility to ensure that that care is for all.

About the Authors

Ahaana Singh is a candidate for an M.Sc. in Global Health at Georgetown University. She received her B.A. in Public Health at the University of California, Berkeley where she nurtured a passion for overcoming disparities in health due to social determinants. She is also founded a health education non-profit dedicated to educating and empowering pediatric patients across communities.

Kemar J. Brown, MD, is a clinical and research fellow in cardiovascular medicine at Massachusetts General Hospital, Harvard Medical School. His research focuses on understanding the fundamental molecular and cellular mechanisms of heart disease. He also studies social determinants of health and predicators of telemedicine use in ambulatory cardiovascular care. Follow Dr. Brown on Twitter @kemar_MD.

Jagmeet P. Singh, MD, DPhil, is a Cardiologist and Professor of Medicine at Massachusetts General Hospital, Harvard Medical School. Dr. Singh is a well-recognized scientist, clinical trialist and educator. His research work is in the field of cardiovascular electrophysiology; with his current efforts focused on healthcare redesign, digital health and medical device innovations. Follow Dr. Singh on Twitter @JagSinghMD.

References:

1. Wiersinga, W. J., Rhodes, A., Cheng, A. C., Peacock, S. J., & Prescott, H. C. (2020). Pathophysiology, Transmission, Diagnosis, and Treatment of Coronavirus Disease 2019 (COVID-19). JAMA, 324(8), 782. doi:10.1001/jama.2020.12839
2. Nishiga, M., Wang, D. W., Han, Y., Lewis, D. B., & Wu, J. C. (2020). COVID-19 and cardiovascular disease: From basic mechanisms to clinical perspectives. Nature Reviews Cardiology, 17(9), 543-558. doi:10.1038/s41569-020-0413-9
3. Bhatia A, Mayer MM, Adusumalli S et al. COVID-19 and cardiac arrhythmias. Heart Rhythm 2020 Sep; 17(9): 1439–1444.
4. Baldi, E., Sechi, G. M., Mare, C., Canevari, F., Brancaglione, A., Primi, R., . . . Savastano, S. (2020). Out-of-Hospital Cardiac Arrest during the Covid-19 Outbreak in Italy. New England Journal of Medicine, 383(5), 496-498. doi:10.1056/nejmc2010418
5. Lai, P. H., Lancet, E. A., Weiden, M. D., Webber, M. P., Zeig-Owens, R., Hall, C. B., & Prezant, D. J. (2020). Characteristics Associated With Out-of-Hospital Cardiac Arrests and Resuscitations During the Novel Coronavirus Disease 2019 Pandemic in New York City. JAMA Cardiology, 5(10), 1154. doi:10.1001/jamacardio.2020.2488
6. Puntmann, V. O., Carerj, M. L., Wieters, I., Fahim, M., Arendt, C., Hoffmann, J., . . . Nagel, E. (2020). Outcomes of Cardiovascular Magnetic Resonance Imaging in Patients Recently Recovered From Coronavirus Disease 2019 (COVID-19). JAMA Cardiology. doi:10.1001/jamacardio.2020.3557
7. Graham, G. (2015). Disparities in Cardiovascular Disease Risk in the United States. Current Cardiology Reviews, 11(3), 238-245. doi:10.2174/1573403x11666141122220003
8. COVID-19 Hospitalization and Death by Race/Ethnicity. (n.d.). Retrieved November 02, 2020, from https://www.cdc.gov/coronavirus/2019-ncov/covid-data/investigations-discovery/hospitalization-death-by-race-ethnicity.html
9. Millett, G. A., Jones, A. T., Benkeser, D., Baral, S., Mercer, L., Beyrer, C., . . . Sullivan, P. S. (2020). Assessing differential impacts of COVID-19 on black communities. Annals of Epidemiology, 47, 37-44. doi:10.1016/j.annepidem.2020.05.003
10. Price-Haywood, E. G., Burton, J., Fort, D., & Seoane, L. (2020). Hospitalization and Mortality among Black Patients and White Patients with Covid-19. New England Journal of Medicine, 382(26), 2534-2543. doi:10.1056/nejmsa2011686
11. Boehmer, J. P., Hariharan, R., Devecchi, F. G., Smith, A. L., Molon, G., Capucci, A., . . . Singh, J. P. (2017). A Multisensor Algorithm Predicts Heart Failure Events in Patients With Implanted Devices. JACC: Heart Failure, 5(3), 216-225. doi:10.1016/j.jchf.2016.12.011
12. Zhao, M., Wasfy, J. H., & Singh, J. P. (2020). Sensor-aided continuous care and self-management: Implications for the post-COVID era. The Lancet Digital Health. doi:10.1016/s2589-7500(20)30220-x