Transcription:
COVID-19 and the Heart

Joey Wahler: Well, COVID-19 can damage heart muscle and function in patients without prior heart issues and those with preexisting heart disease are more likely to contract severe forms of COVID than the general population overall. So what should people be aware of? We're discussing COVID-19 and the heart.

Welcome to Doc Talk, presented by Montefiore St. Luke's Cornwall. I'm Joey Wahler. Our guest is Dr. Neel Khanna, Medical Director of the Cardiovascular institute at Montefiore St. Luke's Cornwall. Dr. Khanna, thanks for joining us.

Dr. Neel Khanna: Nice to be with you.

Joey Wahler: So let's start with, generally speaking, how can COVID damage the heart in those with and also without prior heart conditions?

Dr. Neel Khanna: Well, I would say the major effect of COVID on the heart, if you were to just look at a population of patients who've been positive, is something called a right heart failure. There are two sides of the heart, a right side that's attached to the lungs and a left side, which pumps the oxygenated blood to the body. In people who have severe lung disease, that progresses to something called ARDs, which is basically an end stage of inflammation. It can put so much pressure on the part of the heart that it's connected to the lungs called the right heart, that often that right heart can dilate meaning get bigger and it can function less effectively causing problems with heart rhythms and blood pressure and causing something called pulmonary hypertension, where people can feel lasting effects of shortness of breath and generalized fatigue.

Joey Wahler: So if someone gets COVID and it does impact their heart in some way, is that usually immediately discovered or might symptoms of heart trouble not arise until later on?

Dr. Neel Khanna: I think, you know, this is the major difference between people who have pre-existing conditions and those who don't and people who don't have preexisting heart conditions that they know of or that, that are there often. It takes a while for them to feel their cardiac symptoms, the right heart failure that I just described often happens later in the course of COVID as the inflammation and as the lack of oxygen gets worse with the disease.

In people with preexisting heart conditions who have known plaque in their arteries, or who have a history of heart failure or coronary disease requiring stenting or bypass surgery, those patients often present with cardiac complaints because the active infection sets off a whole cascade of events that may lead to a blood clot formation, or may lead to one of their plaques or stents forming a clot in there and they may present with chest pain and a heart attack. Those patients often we've seen in this COVID pandemic for the last year and a half or two years, that often people who present with chest pain and heart attack and some respiratory symptoms often, they're also COVID-positive at the same time.

We believe that probably they got the infection, got COVID-19, their lungs became inflamed and that set off a cascade that later caused their heart issue, either a worsening of their heart failure or perhaps a heart attack if they had plaque already there.

Joey Wahler: So other than the chest pain that you mentioned, which certainly would get anyone's attention to say the least, what are a couple of other symptoms that could mean COVID is affecting the heart adversely?

Dr. Neel Khanna: I would say the second most common symptom that we see is shortness of breath. Obviously, this is a little more complicated because COVID causes shortness of breath, extreme shortness of breath in cases. So this is a little more complicated and that's why when you seek medical attention and your healthcare provider, either in an emergency room or in an office or in an urgent care setting does an EKG, often we can help distinguish and see whether there's a coexisting heart condition.

There's also very sensitive blood work called troponins, which are basically heart enzymes that are leaked into the blood when there's heart damage that's done. In people who are presenting sick with COVID, often we check these heart enzymes and we see a large percentage of people have positive heart enzymes, meaning that their heart is under stress and that there may be a heart condition co-existing with their COVID infection.

The third most common symptom that we often see is palpitations,meaning people feel their heart racing at times when they don't expect it to raise, they may feel skipped heart beats. In the worst form, they may feel prolonged palpitations and may feel like they're going to faint or feel very lightheaded.

A lot of these patients are coming to us in our outpatient offices because they're not quite sick enough to seek medical attention in the ER, but they have this persistent palpitations that have started after the infection. And often when we put a heart monitor on some of these patients, we pick up that they're having abnormal hearth rhythms. And in the large cases, this may be either a recovering heart condition, something called myocarditis, which is an inflammation or infection of the heart, or it may just mean that the heart is irritable because of everything else that's going on and it's causing these abnormal heart rhythms called arrhythmias that people are feeling usually later on in the course of their COVID infection.

Joey Wahler: Now we often hear during this pandemic, doctor, about people that get COVID who are "symptom free" or have very minor symptoms, but are there people that fall into that category or so they think at first who still are having underlying damage done to their heart in some way as a result?

Dr. Neel Khanna: Definitely. Well, one issue with symptom-free, it depends obviously on the age and the risk factors, often people don't know that they have heart conditions underlying, and it takes a certain amount of stress to bring that out. We've seen a lot of younger patients, and I'm saying closer to the age of 40, come in with their first heart attack while they have their COVID infection. And they did not think that they had underlying heart conditions, but they probably had a plaque there that was forming, a lipid-rich plaque in one of their arteries that the COVID infection caused enough stress on their body that caused that plaque to rupture and they came in with a heart attack. So that's one patient that labels themselves as no pre-existing conditions.

But like we mentioned, people can form blood clots with COVID-19 infection. We have seen that over and over again. So while you may consider yourself as lower risk, and that is important, we have seen many people who are of the lower risk category with no preexisting heart conditions come in with either blood clots in their lungs or in their heart when they have COVID-19 infection. Also, with people who have a relatively quiet course of COVID minimal symptoms, we've seen sometimes a month or a couple of months after they come in with palpitations like we talked about an abnormal heart rhythms. This is much more rare than people with pre-existing conditions, which is why we give the strongest push to get vaccinated to those with preexisting heart conditions that we know of. But not having any preexisting conditions does not necessarily mean that something can't happen when you're infected with COVID also.

Joey Wahler: So to be thorough and safe, simply put, if someone has gotten through COVID or so they think, so they feel, is it still a good idea to go to a cardiologist to make sure nothing has happened there?

Dr. Neel Khanna: I would say it's mostly symptom-based. If you feel a new symptom that you did not have before, whether it be chest pain, increasing shortness of breath after you've recovered from a relatively mild illness or palpitations, you should definitely see either your primary care doctor or a cardiologist to see exactly what's going on because, until we actually test for it, sometimes there are major things that have occurred or damage that has occurred that we don't necessarily know about.

If someone is asymptomatic and feels fine, then often they don't need to seek medical attention from a cardiologist. It's a good idea to see your primary care doctor after you've recovered to make sure that your symptoms are fine, but it's not necessary to seek the attention of a cardiologist after a relatively asymptomatic illness.

One thing we are seeing is that younger people who engage in competitive activities, sports, even college students, high school students who engage in competitive sports, where they really push themselves, often schools and agencies are sending them to cardiologists to make sure even after a relatively asymptomatic illness with COVID, that there isn't a heart condition that has arisen from this, primarily because this segment of population is pushing themselves to an extreme that most people don't. And if they have an underlying heart condition, they're at a higher risk of having an adverse event. So I think as long as you're not in competitive sports and you're relatively asymptomatic, it's something that you can just watch your symptoms. And if you develop symptoms, then you should definitely seek medical attention.

Joey Wahler: Gotcha. So both for those without heart issues and those living with them, if you've not yet gotten COVID as far as, you know, what are a few tips for people to try to ward off that heart damage should COVID arise as best they can in their own everyday lives?

Dr. Neel Khanna: Well, obviously, our major push in the medical community is to get people vaccinated and not necessarily even we're seeing with this Omnicon variant, not necessarily to prevent you from getting COVID, although it does do that to a certain degree, but more so to prevent serious illness. The severity of your COVID infection directly correlates to the degree of heart complications that you can have.

If you have a severe COVID infection requiring a ventilator or supplemental oxygen, those people have a higher rate of heart attack and stroke or blood clots anywhere in the body with the infection. There was recently a study published in Lancet, one of the major medical journals, that show that MI risk or heart attack risk increased almost eight times that of the regular population in people who are not vaccinated. So vaccination is one of the few tools that we really have to prevent serious illness.

Also just staying safe, keeping masked, gloves if you're in a high risk situation with people who have infection, those are always barriers that can prevent you from getting a high viral load if someone does have COVID around you or from preventing you from getting it altogether. But also one of the major lessons that this has taught us is that underlying health, meaning your risk factors are incredibly important in deciding how serious your COVID infection will be and whether you have heart complications. Controlling your risk factors, meaning trying to keep your weight as ideal to your body weight as it should be, smoking cessation, controlling your blood pressure, cholesterol and diabetes. All of these are risk factors in determining how severe your COVID infection will be.

One thing we have definitely seen is that people who have less risk factors and who are healthier and not obese have less severe cardiac complications and also less severe COVID-19 infection.

Joey Wahler: And then in closing, especially since the pandemic, generally speaking, how often, doctor, would you say a heart exam is needed both again for those with, and without heart disease?

Dr. Neel Khanna: Generally speaking, you know, often we recommend that people have an EKG done every year once they're over the age of 40, and some people recommend 50, just to see and make sure that there aren't any changes. This has shifted over time where some primary care doctors don't do it, some do.

The primary goal is to be that if anyone has a strong family history or they have underlying risk factors, like high blood pressure, obesity, hyperlipidemia, high lipids, high cholesterol, or diabetes, that they seek medical attention. And often, they should see a cardiologist to make sure that they don't have underlying heart conditions that are brewing that could become a factor later in their life or if they get an infection like COVID.

Joey Wahler: We often hear the old term matter of the heart and the impact of COVID can certainly be just that as we've been discussing. Dr. Neel Khanna, Medical Director of the Cardiovascular Institute at Montefiore St. Luke's Cornwall has been with us. Dr. Khanna, thanks again.

Dr. Neel Khanna: Thank you so much.

Joey Wahler: And for more information about the Cardiovascular institute, we invite you to visit montefioreslc.org. That's montefioreslc.org. And please remember to subscribe, rate and review this podcast at all the other Montefiore St Luke's Cornwall podcasts. I'm Joey Wahler.