Transcription:
COVID-19 and Cardiology Effects

Caitlin Whyte: This is Doc Talk presented by Montefiore St. Luke's Cornwall, I'm Caitlin Whyte. And today we are discussing COVID-19 and cardiology effects. Anthony Patrello is the Medical Director of Cardiovascular Services at Montefiore St. Luke's Cornwall Cardiovascular Institute. So Dr. Patrello tell us about COVID-19 and how it is affecting those who have preexisting conditions such as heart disease?

Dr. Anthony Patrello: So that's a broad question. The problem with COVID-19 is that the breadth of manifestations in people is extremely broad. It can range from a very mild viral type upper respiratory tract infection to a viral pneumonia, to severe viral pneumonia with an extreme inflammatory lung reaction, and associated with that all types of issues with multi-organ failure, including cardiac failure. And who gets that and who gets where on the spectrum is extremely variable and not precisely well known. Certainly the more preexisting conditions that you have, including hypertension, obesity, diabetes, a history of heart failure in the past, the more likely that you're going to develop one of the more complicated ends of the spectrum, but not necessarily. I've certainly seen younger people without any severe preexisting conditions have a severe course. And I've seen older people who've had severe underlying cardiac conditions do quite well. So it is quite variable.

The way that COVID-19 can affect the heart is also extremely variable. And that's just because of the nature of the disease process. It can cause true heart attacks, which we've seen. So COVID-19 can cause an increase in clotting throughout the body. We've seen people have blood clots in the legs, blood clots in the lungs, and from the same increase in blood clotting, you can get increase in thrombus formation and blood clots in the arteries of the heart and actually cause true heart attacks, or sort of the typical heart attacks that we, that we see even without COVID-19, but it is causing an increase in incidents of that. Oftentimes when people have traditional heart attacks, there's only one blockage, that's the sort of culprit lesion that we end up fixing. Oftentimes in COVID-19 it's multiple vessels involved at the same time. The reason why that happens is not entirely known.

It could be because that the virus affects the lining of the blood vessels called the endothelial cells. In autopsy studies they've seen that there may be some inflammation of that lining of the endothelial cells. And that may trigger this increase in clotting. It may just activate the clotting pathway by itself as another infectious disease processes that we see, not only does it cause clotting in the large arteries that can cause clotting in the small arteries as well. It can cause micro thrombi, that can happen in the lungs. It can also happen in the arteries of the heart. So sometimes an EKG looks like a patient's having a heart attack and we bring them to the cath lab and we take a look and the large arteries that we can see are actually all open. And the presumptions that there maybe thrombi or thrombus formation or clot formation in the small microscopic arteries that we can't see on a coronary angiogram. You can also develop something called a mild carditis, which is inflammation of the heart muscle, which can also lead to a weakening of the heart muscle and heart failure.

So there's nothing wrong with the arteries of the heart themselves. It's just inflammation of the muscle. You can get pericarditis, which is inflammation of the SAC around the heart and fluid could build up around the heart and you can also get something called a stress cardiomyopathy. So when the heart is under an enormous amount of stress, there's nothing wrong with the heart itself, just the heart is under an enormous amount of stress. You can get dilation and ballooning of the heart, typically of the tip of the heart. Sometimes that happens with emotional stress, but that can also happen with extreme physical stress, such as an infectious process, and we've also seen from an electrical standpoint, arrhythmias as well. Patients having a fairly dangerous arrhythmias and oftentimes which could be fatal heart arrhythmias as well. So it really can affect almost any aspect of the heart in terms of the heart muscle, the lining of the heart, the vessels of the heart, and the electrical system of the heart really can all be involved.

Host: So should someone stop taking their medications such as ACE inhibitors or ARBs? What do you want people to know about continuing their care? If they're already on these medications during this time?

Dr. Anthony Patrello: That's a great question. There's been a lot of controversy about that. Initially, the thinking is that the way that the virus enters into the cell is by binding to a receptor called the ACE2 receptor. And there was concern that people who are taking ACE inhibitors or ARBs, they may upregulate ACE2 expression and provide more receptors for the virus to bind to, and therefore cause a more severe viral reaction initially, very early on, you know, there was some concern that may be the case. Since then, there's been a lot more data that's come out and it doesn't appear to be the case. There is no relationship between people who are taking ACE inhibitors and ARBs and the severity of their disease process. And oftentimes people who are on ACEs and ARBs are on it for a really good reason. So they're either on it because they have high blood pressure, they're on it because sometimes because they have kidney disease, they're on it because they have a history of heart failure, and abrupt cessation of that medication can cause a deterioration of the underlying reason why they are on it in the first place.

So if you're on it because of heart failure and you stop taking your medicine, you may go into decompensated, heart failure, even without having the virus. Same thing with hypertension. If you have high blood pressure and you're well controlled on an ACE or an ARB, and all of a sudden you stop taking it, you may get rebound very severe elevations in blood pressure, which can cause adverse effects as well. So you should continue taking the medicine as prescribed. Now, I don't know if I would necessarily start an ACE inhibitor or an ARB brand new in somebody who actually has COVID and use that as the time to start the medication from scratch. But I also, you shouldn't stop the medication if you've been on it already and develop and contract the virus. And this is a recommendation not only held by the physicians here, but it's, it's a recommendation that has been given down by the American College of Cardiology and the governing body within cardiology and medicine who have looked at this and have recommended against stopping the medication.

Host: Early in the pandemic, we heard a lot about people almost hoarding, you know, planning supplies in advance, when it comes to these medications, what are the supplies like now, should people still kind of have few months on hand?

Dr. Anthony Patrello: In terms of hoarding medications, it seems like a lot of people were doing that for a medication called hydroxy chloroquine, which there was some early data to suggest that that may have some benefit for the virus. Since then, there's been quite a bit of data to suggest that there is very little role for hydroxy chloroquine in COVID-19. And it may actually even cause harm. Not only should you not hoard the medication, but probably right now, it's not even in our armamentarium of medications to give patients who have COVID-19. So I certainly wouldn't hoard it and I wouldn't advise even taking it. In terms of regular medications, I haven't seen too much in terms of pharmacies are running out of medicine. Really actually clarify that by saying I haven't seen it at all. There hasn't been a case for where I had a patient, tried to fill a medication in a pharmacy and then come back to me to tell me that they had run out of medication, didn't have it available.

 

So we're not seeing, you know, sort of like what we saw in supermarkets, where people were running out of supplies and supermarkets and they were trying to hoard up to prevent them from running out. We haven't seen that at least in the local pharmacies here at all. So really, they have access to all the medications that they need. And the concern would be that it's a self fulfilling prophecy. If you start hoarding medication, then you will create a run on medications and you will cause a shortage for other people. But if everybody just fills their prescriptions as necessary, even if it's a three month supply for 90 days, which is typical for most, we'll have enough for everybody.

Host: How are you utilizing telehealth to help people with heart conditions? And what would you want them to know if they have to come in as far as screening patients for COVID symptoms?

Dr. Anthony Patrello: So telehealth has been really revolutionary in medicine over the past couple of months, it's given us the opportunity to communicate with our patients and even we can actually physically see our patients. There's only so much information you can get over the phone, but you'd be surprised how much of a physical exam you can do through telemedicine. For my heart failure patients, you know, I can see if they're developing swelling in the, in the, in the ankles. I can see how they're breathing. If their breathing looks labored, even ask them to walk around their house and to see how they're breathing when they're doing that. I can even get a sense about what their filling pressures are in their heart by looking at the veins in their neck. So there is quite a bit of information that you can get from, from a telehealth physical exam and just physically seeing the patient and seeing how they're doing provides so much comfort. There is obviously tons of patients who have chronic cardiac conditions and this pandemic, you know, we're several months into it.

Now there is no clear end in sight patients with chronic cardiac conditions. Can't go for months and months and months without getting their medical care. They're going to develop decompensated heart conditions and end up in the hospital for other reasons that are not COVID related. So we have been using telehealth as a means to stay in contact with our patients and make sure that they're feeling okay and they're not letting their health go by the wayside. Now cardiology is a little bit of a different field than the others, in that there is only so much that you can get through telemedicine. I can't listen to the heart sounds. I can't listen to the lungs. And EKG is a really critical part of a cardiologist examination and evaluation. And we're obviously unable to do that. Most of the time through telehealth, there are some apps on your telephone that sometimes you can download that can give us a rough sense of an EKG, but a full 12 EKG is not really possible.

So if there are any significant symptoms and it's not just a, you know, routine three or six month health checkup, but you're having some new symptoms that need to be evaluated, that really does need to be evaluated in a doctor's office. Certainly we at the heart center, and I know other cardiologists in the area as well, are seeing patients. We take extra precautions to make sure that the office is completely clean. We are minimizing contact with patients. There's nobody waiting in the waiting room. We're making sure everything is sterilized between patients in the exam room. Everybody's wearing masks, there are shields in front of the schedulers to make sure that there is no trying to minimize interactions. So there's a lot of precautions being taken and patients, I think it's important that they should not be scared to come to see their physician, especially if they're having symptoms. There's been a lot of data that has been published to suggest that the incidents of heart attacks in hospitals recently are way down.

And that sounds like it should be a good thing, but really it's probably not because I don't think that people got any healthier over the COVID pandemic period. What I think more likely is happening is that people are not going to the hospital when they're having their heart attack, or they're not seeing their doctor to diagnose their heart attack and they're riding it out at home. And we have seen that because the patients who actually do end up coming, have been on average far sicker than they have been in the past, more in the later stages of the disease process than in the past. And it's always harder to treat something when you're farther into the process then it was when it's earlier on. So I do urge people to use telehealth as a mechanism because there is value in that, but certainly to not hesitate in seeing your physician, if there's anything more serious going on.

Host: Great, Dr. Patrello, is there any other advice you want to offer to patients with heart conditions as they navigate this unprecedented time?

Dr. Anthony Patrello: What I would say is that I think it's important to be cautious, to make smart choices, proper hand hygiene, wearing your mask as appropriate. But I also think it's important not to live in complete fear. Your physician is available to see you if you need to. Hospitals, at least now in the New York area are far less overwhelmed with COVID patients than they were in the past. In fact, the numbers in the hospital are quite low at the moment. So there are medical resources there if you need it. And the worry is, is that the panic that people have and the living in fear that people have, will prevent them from really taking care of themselves and doing what's right. And I think it's important to be smart. We have to control the spread, and doing that by social distancing and wearing protective equipment that's important, but it's also important that you take care of yourself, that you maintain your proper diet.

I understand that if you're home and you're not going out, and the refrigerator is so easily accessible, it's easy to get off your diet. It's important that we don't do that and that we stay on your diet. I understand that, you know, with being in the house, it's harder to get out. You know, your, your local gyms are closed. Your cardiac rehab facility may be closed and it's harder to do regular exercise. It's important to try to do that, obviously in a socially distance manner, but to get outside into walk into, and to maintain physical activity, it's important to keep, to try as much as you can, to keep the same kind of lifestyle habits that you had before obviously modifying them, but keeping them, even in the COVID errors, that things don't go completely off the rails. And obviously from an emotional standpoint, physicians are available to talk with you if needed, you know, not only about your physical wellbeing, but emotional wellbeing, there's obviously a lot of emotional stress going on because of what's going on worldwide. And it's important that you talk about those things, and seek advice if you need it from your physician.

Host: And that wraps up this episode of Doc Talk presented by Montefiore St. Luke's Cornwall. That was Anthony Patrello, the medical director of cardiovascular services at Montefiore St. Luke's Cornwall Cardiovascular Institute. Head on over to our website at MontefioreSLC.org for more information, and to get connected with one of our providers. Please remember to subscribe, rate and review this podcast and all the other Montefiore St. Luke's Cornwall podcasts. For more health tips and updates on the latest medical advancements and breakthroughs, follow us on Facebook and Twitter. If you found this podcast informative, please share it on your social media and be sure to check out all the other interesting podcasts in our library. I'm Caitlin Whyte. Thank you for listening.