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Scott Webb (Host): To truly defeat COVID-19, we must get to herd immunity. And in order to get there, we need as many people as possible to get the vaccine. But many people have questions and concerns about the vaccine, including those with preexisting heart conditions. And joining me today, is Interventional Cardiologist, Dr. Richard Gerber. He's here to encourage all of us to get the vaccine when we can, especially those with preexisting heart conditions. This is Ask the Experts, the podcast from Salinas Valley Memorial Healthcare System. I'm Scott Webb. So, Doctor, thanks so much for your time today. We're talking about COVID-19 and the heart primarily. So, let's do that. Can COVID-19 affect the heart even when a person has no history of heart problems?

Richard Gerber, MD (Guest): I do think that we see certainly a higher prevalence of cardiac manifestations and cardiac complications in patients who have preexisting heart disease. But I would say that in my personal experience and in the literature, we do see patients who have their first ever heart attack and their first ever heart problems in association with an acute case of the Coronavirus.

Host: You know, that is kind of frightening news. And I'm wondering if you can give us an overview of how the virus really affects the heart.

Dr. Gerber: Well, sure. Yeah, there quite a few manifestations of and cardiac complications of this illness. When patients are infected with the Coronavirus, there seems to be this oftentimes fulminant activation of the inflammatory system. So, when the inflammatory system is activated, a whole cascade of problems can arise including injury to the heart muscle, weakening of the heart, which can worsen adverse pressure relationships in the heart and lungs and cause fluid in the lungs. The clotting cascade in the veins and arteries can be inappropriately activated and people can have inappropriate blood clots form in various parts of the body that can cause a heart attack, can cause stroke and can cause other mischief elsewhere. Patients with pre-existing conditions like congestive heart failure can have their heart failure made worse by an episode of COVID-19. And we see COVID-19 patients have unstable heart rhythms as well.

Host: Yeah. So, it sounds like there's a myriad of things to consider both for people with preexisting conditions and those, you know, have had no heart issues before. When we think about the heart conditions that people may have, does that put them at higher risk of developing a severe case of COVID-19 and if so, why is that?

Richard Gerber, MD (Guest): Yeah. So, what we've seen is that very often that the patients that have preexisting heart disease will have some form of injury that can be detected when they're admitted to the hospital with an episode of COVID-19. And about one fourth or 25% of patients who are hospitalized with an episode of COVID, will have this sign of heart muscle injury and it's most frequently detected by measuring a protein in the blood called troponin.

And when we measure troponin, troponin is a protein, it's an enzyme. It's very specific to the heart muscle. And when we can measure that in the blood in association with an episode of a severe COVID-19 illness there's a much greater risk for adverse outcome. Usually meaning a longer hospital stay, a greater need for being put on artificial means of life support and higher mortality.

So, what we've seen is that as I mentioned about a quarter of patients admitted with COVID-19 will have this elevation of troponin that will very often oblige us to look at the function of the heart with an ultrasound of the heart, an echocardiogram. And if in addition to the troponin being elevated on a blood test, if the echocardiogram is also abnormal, the risk goes up further.

So, just to put it into perspective, the rate of mortality in hospitalized patients with COVID-19, the rate of death, can vary, but in one particular study that I'm thinking of that I'm referencing from the American College of Cardiology; if there's no myocardial injury, if there's no muscle, heart muscle injury, the mortality rate in hospitalized patients can be about 5.2%. But if their troponin is elevated, their mortality rate can go up to about 18 or 19%. And if they have this troponin elevation and an echocardiogram showing that their heart muscle is weak, then the mortality rate can be as high as 32%. So, you can see that these patients who have COVID-19, but also have underlying heart disease or whose hearts are affected by the virus, really are in a much, much more dangerous and vulnerable situation.

Host: Yeah, it sounds like it and is that one of the complications in all of this, of all the many complications, is treating people with COVID-19 and these heart issues that either the COVID has caused or that they already had, and the COVID has made worse? Is it difficult or more difficult to treat these things simultaneously?

Dr. Gerber: Yeah, I would say it certainly is. What our experience has been is that these patients that have either pre-existing heart disease and then get a severe case of the virus, are sick enough to be hospitalized, they're much more likely to have these kinds of adverse outcomes, meaning blood clots in their veins or arteries. They're much more likely to suffer a stroke or a heart attack as the result of the acute illness. Their heart failure is much more likely to be worse. Their rhythm abnormalities may become more unstable, more difficult to manage. So, I think whether you’re somebody with pre-existing heart disease and comes into the hospital with an episode of COVID-19 or have your very first episode, it seems to be a particularly vulnerable population.

Host: Yeah, it does sound like it. When we talk about the populations, does gender matter or are cigarette smokers at higher risk?

Dr. Gerber: So yeah, I would say that gender does seem to be something that has been identified in this past year. That there are gender differences that the outcomes for men are worse than women. The mortality rate for this disease in hospitalized patients is higher in men than women. I don't think we exactly understand why that is in an intuitive way. I think people think that obviously there's hormonal differences between men and women. And then whether it's because having more testosterone makes men more vulnerable or having more estrogen makes women more protective is not entirely clear, but there does seem to be a higher mortality rate overall in the COVID-19 patients with men rather than women as far as the drivers of bad cardiovascular outcomes with COVID-19, I think that a lot of those things are the same as the drivers of increased risk for heart disease overall.

So, patients that are obese or have a higher measured adipose fat tissue in the body are at higher risk of a bad outcome. Patients that are diabetic or just have high measured blood sugars seem to do worse. Lipid abnormalities, having elevated cholesterol or triglycerides in the blood, is a marker for increased risk, as is an elevated blood pressure or known systemic hypertension. And all of those things can be in and of themselves, a marker and a driver of a bad outcome. And the more of those things that you have, the more risk you have. And I would also add that our highest risk and our highest mortality nationwide and throughout the world is in the aged, in the elderly, right? So, the older you are, the worse your outcome is as well.

Host: Yeah, it does seem so and just listening to you, I'm thinking to myself, you know, there's so much. You know I have been hosting these back since March, you know, and there was very little that we knew then, and we know so much more now, but there's still so much more to learn. When we talk about COVID-19 and what it can cause that we know so far, do you believe, or have you seen evidence that it can cause heart problems such as arrhythmias, myocarditis, things like that?

Dr. Gerber: So, yeah, I think that our experience has been this multiplicity of and vast array of complications. We've seen patients inappropriately form blood clots, especially those sick enough to require intensive care unit management and those sick enough to be on ventilators. They can have clots form in their veins, that travel to the lungs. That's called pulmonary embolus and is life threatening. We've seen patients have arterial clots, which can cause stroke in the brain or can cause heart attack. We can see patient's heart failure where in addition to the virus causing this inflammatory reaction in the lungs and fluid in the lungs, we can also see adverse pressure relationships of fluid in the lungs. And it's much more difficult to clear fluid from the lungs. And I think that we've also seen patients with unstable and very difficult to control rhythm abnormalities, such as atrial fibrillation as well.

Host: You know I think one of the questions a lot of us have, is if we think that we have COVID or tested positive with COVID, maybe we shouldn't go to the hospital, but what if we have a preexisting heart condition and maybe there's some confusion there for people about exactly what to do and when to do it. So, maybe you can kind of set things straight a little bit.

Dr. Gerber: Yeah. So I think that the elderly patients and patients with pre-existing illness certainly need to be on heightened alert. There's interestingly been a decrease in things like non-COVID related admissions for heart attack, for stroke, for exacerbations of heart failure. And we're not really entirely certain and clear about why that's happened this past year. Are people staying home when they shouldn't be, and having larger heart attacks that are going to have adverse complications down the road? Is the same thing happening with stroke where people are suffering through a stroke at home and maybe surviving the stroke and then going to have more disability later on? Are we going to see sort of this downstream unintended consequences from other non-COVID related illnesses like heart disease that gets unrecognized because people are fearful to come to the hospital. So, our message has been that there are many things that people can have major disability and death from besides COVID-19.

And if someone really thinks they may be having a heart attack or a stroke, or, some real aggravating factor in their underlying heart disease, they really shouldn't delay coming to the hospital. The hospital has taken enormous steps to make it safe. There is a very effective triage and segregation of patients with and without COVID-19. So, the emergency department and the hospital really remain a very safe place to come, if you think you're sick with or without COVID-19. And we really don't want patients to delay treatment for COVID-19 or for their other serious life-threatening heart and non-cardiac related diseases because they're afraid to come to the hospital and they're afraid they might get COVID by coming to the emergency room or coming to the hospital.

Host: I'm glad you said that. That's always the message here is don't delay care. The safest place is the hospital, of course. And we mentioned earlier, too, about the COVID-19 vaccine. Is there any reason why people with heart disease shouldn't get the COVID-19 vaccine and really, maybe you can stress just how important it is when your number's up, when you get called, how important it is that you go and get that shot in your arm?

Dr. Gerber: That's a really important question. I think that there has been some concern in some of our population about the safety of this vaccine. I think it's a novel kind of vaccine, this new messenger RNA vaccine. And it's really a tribute and a testament to modern science that the pharmaceutical companies were able to develop these effective and safe vaccines in such a quick, short period of time.

I think that the public should feel safe that the effectiveness of this vaccine and the safety of this vaccine has been validated in tens of thousands of patients. And I think that if we are going to safely come out on the other end of this pandemic nearly a year in now, we're going to need to have this so-called herd immunity, and the way that we're going to achieve that is to have everybody get vaccinated as quickly as possible.

I think appropriately so, the elderly are now, amongst those that are being vaccinated because they're are amongst our most vulnerable and people with chronic conditions such as heart disease, cancer, diabetes are at increased risk is as well. So I really think there are very few exceptions for getting vaccinated and I've been encouraging virtually all of my patients to get vaccinated. When it's your turn, you should definitely take the opportunity and get vaccinated.

Host: Yeah, I couldn't agree more. More than I know you see a lot of chatter on social media about you know, which vaccine Moderna, Pfizer, whatever it is. Listen, you don't get to pick. But when your number's called, you go and get those shots, as you say, that's the only way we're going to get to herd immunity. And if people are, you know, fatigued with just the talk about COVID or wearing masks, whatever it is, that's where we need to get. If you want to stop wearing a mask, we need to get to herd immunity. And the way we get there is for everybody to get vaccinated. So, I'm with you doctor, as soon as my number is called, I will be there as fast as I can, safely, but as fast as I can, of course. And when we talk about heart patients, heart disease, and the vaccine, any reason why anyone should think about changing their medication doses? Have you seen anything along those lines?

Dr. Gerber: So there was some early concern that patients on so-called angiotensin converting enzyme inhibitors or angiotensin receptor blockers, that being on those two medicines, which are categories of medicines that are commonly used for hypertension and heart failure, that there might be some increased risk of getting sick with COVID-19. That's been carefully looked at and has been refuted. So, there really is no reason that those medicines or any of people's heart medications should be discontinued or stopped out a fear that it might change or increase the risk of getting sick with COVID-19.

Host: That's good to know. And I want to just take a step back here as we get close to wrapping up. Let's just go back over this you know, cardiologist 101. What are the signs and symptoms of a heart attack that people should be on the lookout for?

Dr. Gerber: Anybody who has the sudden onset of heaviness, pressure, burning, tightness, squeezing in their chest, their neck, their jaw, their shoulder, or their arm, a sensation that really is new to them, foreign to them, something that is out of their usual experience, should pay very close attention to it. And if it persists and doesn't go away, especially if it's in association with an abnormal amount of sweating or dizziness, feeling breathless or faint. Those are all manifestations of a heart attack that should not be ignored. And the message that I would want to give to the public would be to call 9-1-1 and seek emergency attention as soon as possible if one has any of those symptoms,

Host: As we wrap up here, anything else you want to add today as just sort of a period at the end of the sentence? What are your takeaways?

Dr. Gerber: So, I think what I would say is that we're in a new year, there's some reasons for optimism. In our own community, the numbers of positive cases is going down. The number of hospital admissions are going down. And we have a vaccine, so those are all positive things. But we need to be vigilant. We need to continue to try to do the best that we can as a community together to get this thing under control. That means all the things that you've heard, wearing your mask, washing frequently, maintaining social distancing, avoiding gatherings. And I think that if we can do of those, all of those things and stick with it, we're going to have a safer community, not just for our cardiac patients, but for everyone.

Host: Perfect way to end and you're so right to just be right resilient. Stay positive, vigilant. So, doctor, thank you so much for your time today and you stay well,

Dr. Gerber: Okay, thanks again for including me. I appreciate it.

Host: For information on COVID-19, please visit svmh.com/coronavirus, and we hope you found this podcast to be helpful and informative. This is Ask the Experts from Salinas Valley Memorial Healthcare System. I'm Scott Webb. Stay well, and we'll talk again next time.