As COVID-19 Drags on, the Cardiology Fallout May Haunt for Years

The COVID-19 pandemic upended everyone’s lives first in 2020, then again in 2021, and the cardiology field was no exception: care was delayed, appointments were done at a distance, risk factor control fell by the wayside, and patients faced unprecedented stress, isolation, and lifestyle changes that put their health at risk. On top of this, SARS-CoV-2 itself can cause cardiovascular complications plus as-yet-unknown long-term effects.

The need to ensure that patients’ cardiovascular health doesn’t suffer due to the pandemic as it stretches on “is a hugely important topic,” Donald Lloyd-Jones, MD (Northwestern University Feinberg School of Medicine, Chicago, IL), president of the American Heart Association, told TCTMD. “And it is going to haunt us for years to come, very clearly.”

Early on, lockdowns across the globe led many people to postpone procedures when possible and skip diagnostic tests. Even more worrisome was the fact that fear of contagion made some reluctant to seek immediate help when experiencing a health emergency, resulting in the “missing STEMIs” phenomenon.

With time and creativity, these short-term obstacles have been less of a concern in 2021 than in the year prior, Lloyd-Jones observed. He pointed to a survey from the US Centers for Disease Control and Prevention (CDC) showing just 19% of US adults delayed or didn’t receive care this summer, as compared with 45% of respondents during the same period in 2020.

Still, cardiologists who spoke with TCTMD said that they expect the road to full recovery to be long. Early data hint the fallout from the interruptions may have just begun, with rising hypertension rates, less blood pressure control, falling physical activity, and worsening diets. As early as 2020, deaths from hypertensive disease and ischemic heart disease were increasing 17% and 11% faster compared with 2019, with even more drastic changes seen in hard-hit areas like New York City. Any changes in risk factor control may be compounded by COVID-19’s cardiovascular footprint consisting of myocardial injury, arrhythmias, heart failure, vascular dysfunction, and thromboembolic disease.

All this begs the question of what clinicians have learned over the last 2 years and how that might help as they try to play catch-up.

Telehealth in Perspective

One unifying theme among those who spoke with TCTMD was the need to take a close look at telehealth, which took off in the pandemic’s earliest days as a way to avoid contagion. Gradually, with the emergence of COVID-19 protocols and vaccines, patients have been returning to in-person care as needed and reserving virtual visits for less hands-on matters.

This is not going to be one of those things where we snap our fingers and everything magically goes back to where we were in February 2020. Donald Lloyd-Jones

Preventive cardiologist Vijay Nambi, MBBS, PhD (Baylor College of Medicine/Michael E. DeBakey VA Medical Center, Houston, TX), called for balance. “Don’t get me wrong, there are a lot of good aspects [to telehealth] but you have to find that good happy medium, where video and in-person becomes melded,” he commented, adding, “You get a better rapport when you’re face-to-face as opposed to on telehealth,” where a good internet signal isn’t guaranteed and there can be more distractions.

Patients are warming to the idea of getting back to the office, although “part of it is obviously a little consumer driven,” said Nambi. “Some do not want face-to-face as yet, and every 2 to 3 months there’s a new variant or a new scare. . . .There are others who just want to come no matter what. Even during the peak of the pandemic, there were people who said, ‘You know what, I just want to come in and see you. I cannot do this over the phone.’”

Anu Lala, MD (Icahn School of Medicine at Mount Sinai, New York, NY), who specializes in heart failure and transplant, pointed out to TCTMD that adoption of telehealth outpaced knowledge about its impact. “Yes, the use of telemedicine and remote monitoring has increased undoubtedly, but what we don’t know is how the increased use of these modalities will impact outcomes [in the long run],” she explained. “Whether it’s better or worse we don’t quite know.”

She emphasized that discussions about this topic need to consider issues of equity. “Who has access to these modalities? It’s not that everyone has really great Wi-Fi and can connect with ease or has the know-how or the literacy to be able to do that,” said Lala. “So I think we have to be really mindful of the populations that we serve in that capacity” as the evidence base grows.

One positive shift is the recognition that, anecdotally at least, the shift to virtual has also helped clinicians realize “the utility of just being able to pick up the phone and call patients a little more directly,” she added.

Need to Reconnect

Rebuilding a personal connection, whether virtual or face-to-face, is a pressing need, said Salim Virani, MD, PhD (Baylor College of Medicine/Michael E. DeBakey VA Medical Center). The power to achieve that lies with healthcare providers, he stressed. “As clinicians we definitely have a lot of control over this, and I think we should exercise that control now. If not now, when, right? This is a defining point not just for COVID-19 but even for any noncommunicable disease.”

However, the onus isn’t entirely on clinicians, as Lloyd-Jones specified. Bringing patients back into the fold is a “health systems issue,” he said. “We need to systematically identify what their numbers are now and what their needs are.”

This is especially true given the inequities in healthcare exposed by the COVID-19 experience, commented general cardiologist Erica Spatz, MD (Yale School of Medicine, New Haven, CT), who’s written on the topic of how to apply these lessons in cardiovascular medicine.

She suggested electronic health record (EHR) systems could be leveraged to see patterns. “Who are we missing? Who’s not coming in for care? Who’s not presenting, whether in person or by telehealth? Right now, those people are in the shadows,” Spatz said, adding, “Many of us practice within large health systems and we have great EHR data and should be doing much more proactive population health.”

When patients do return, it’s crucial to “take an expansive view of their total health and well-being, because I think that’s inseparable from their cardiovascular health,” stressed Spatz. “If a person is under stress, if they’re struggling to make ends meet and can’t afford food on their table, or if they are suffering from trauma or grief, all of that affects cardiovascular outcomes.” And finally, she noted, technology should be used to help make it as easy as possible for patients to engage with digital health and enhance care.

Obviously anything in prevention of cardiovascular disease is a long haul, and you don’t know if you’ve felt the brunt of it fully already or not. Vijay Nambi

Virani also stressed the need to spend more time engaging with patients than ever before, with the knowledge that the COVID-19 era has spawned issues with mental health, money problems, and other difficulties. When people are “in the middle of a pandemic and dealing with more urgent, emergent things,” their ability to maintain medical therapy and healthy habits naturally decreases, especially for those juggling several chronic diseases, he said.

Empathy is key. When trying to inspire patients, learn more about their daily lives, Virani suggested. “If I am a 45-year-old woman who has diabetes and hypertension . . . , if I just hear, ‘Go walk every day for 30 or 45 minutes,’ and do this or that, but if I have my kids who are not even able to go to school and I take care of them and have an elder parent living with me as well, this is not going to go well.” Furthermore, keep in mind that financial strain could limit patients’ ability to purchase medications, especially since many have comorbidities requiring attention, Virani added.

Even those who are “very well resourced may not have that emotional reserve now” to accurately follow instructions, so it’s worth being mindful of that during appointments, he noted. “It only makes us human to assume we fall off the track.”

Something that also should happen at every visit, said Lloyd-Jones, is educating patients that “the rules of engagement when you have an emergency have not changed. You call 9-1-1 for the same reasons you did in 2019. It should not have changed in 2020. Unfortunately it did, and we lost quite a few lives at home that should have come to the hospital. . . . We should make sure not to repeat that again.”

The Test of Time

Virani predicted that eventually, even if it’s not fully apparent yet, nonadherence to lifestyle measures and preventive therapy during the pandemic will take a toll. And while the resulting cardiovascular event rates may turn out to be seemingly low, these would translate into large numbers on a population scale. “It’s just started,” he said. “These are long-term diseases [that] lead to impacts over 1, 2, 3, 5 years.”

Similarly, Nambi said it’s still unclear how much—at this point—poor risk factor control has triggered adverse events, “because obviously anything in prevention of cardiovascular disease is a long haul, and you don’t know if you’ve felt the brunt of it fully already or not.”

What also will take time, he and others said, is regaining control of these risk factors.

This is partly because people who are the most vulnerable are also the least likely to seek care, noted Virani. “Healthier patients generally are more likely to present to offices, because they generally have more resources and don’t have as many other things to deal with in life.”

It only makes us human to assume we fall off the track. Salim Virani

Lloyd-Jones agreed that it’s important to understand how social factors are affecting people’s return to the clinic. “We see that people with more means are able to engage more quickly and effectively back with the health system [thanks to] the flexibility to have hours to get to the doctor,” he said. This is more true now than ever since people in frontline work positions are “considered critical and they just can’t take the time to even reengage with the health system yet.”

In addition to the influence of socioeconomic position, there’s the fact that caregiving duties have fallen disproportionately on women versus men during the pandemic, and there remains a persistent rural-versus-urban divide, he observed. “There are significant stressors on rural populations, because we’ve lost so many healthcare providers and hospitals and other ways for people to connect [in these] settings.”

Until patients return, allowing for in-person measurement of their blood pressure, blood sugar, and cholesterol, it’s impossible to know how much has changed, Lloyd-Jones noted. Chronic conditions like hypertension, diabetes, and hypercholesterolemia “really require carefully monitoring longitudinally over time, and repetitively.”

In his experience, the news has often not been good. “There are people who had had pretty good blood pressure control, then disconnected, [and] now they’re back and their blood pressure’s in the 140s or higher,” Lloyd-Jones said. “We’re not going to fix that immediately. That’s the real problem here: it just takes time and multiple visits often to get somebody back to that level of control and also to reinvigorate the lifestyle things that were working to help them control their risk factors.”

During that “lag time,” he continued, “things are going to lead to cardiovascular events that would not otherwise have happened. So we’re in a bad place. . . . This is not going to be one of those things where we snap our fingers and everything magically goes back to where we were in February 2020.”

But Lloyd-Jones did see some reasons to hope, such as wider use of monitoring technologies.

Hypertension is an area where “we can really empower people to do better with self-management if we provide them with the means to do so,” he said. With a blood pressure monitor as well as training on how to use it, patients are able to remotely share their results with a healthcare provider—preferably a pharmacist, nurse practitioner, or medical assistant rather than a physician—who can help them adjust their medication accordingly.

What’s necessary, he said, is to “beef up” the variety of clinicians caring for patients as well as the public health infrastructure. Burnout has meant “there are just fewer people who are providing patient care now,” Lloyd-Jones added. “There’s a lot of snowballing and interacting problems here.”

Nambi, too, highlighted the value of pharmacies and other facilities in providing care, as well as remote monitoring. “Trying to decentralize and going to small, local communities [is] an important way to move forward,” he said.

Managing COVID-19 Sequelae

All of these evolutions are occurring on the backdrop of COVID-19 itself. Lloyd-Jones described cardiologists at academic medical centers as “all flat-out” dealing with both the difficulties of making up for lost ground in cardiovascular care as well as seeing “long COVID sequelae.”

Most frequently, patients’ lingering symptoms are shortness of breath and tiredness during recovery from the disease, Nambi said. “Now, how much of it was from whatever COVID did to their lungs [or] their heart or a combination therein, that’s the thing that has to be teased out.” And as with all major illnesses, it may simply be a matter of time, he pointed out. “It’s going to take you weeks, months to get better [and] back to what your baseline was.”

Everyone’s living through a dystopian time with a lot of struggles, so the health of the general population is not well. Erica Spatz

This complexity of overlapping organ involvement has necessitated a multidisciplinary approach, Spatz said, noting that early in the pandemic institutions like hers took this route for critically ill patients thought to need ongoing cardiovascular care after hospital discharge. “But very quickly the clinic evolved to accommodate a very different kind of patient we were seeing,” she recalled, “and these were people who were mostly not hospitalized for COVID, did not have severe infections, [but] had mild infections and never really recovered. . . . Those referrals started to really overwhelm the other group, and that’s by and large most of the patients that we see today.”

Lala made a similar point: “Patients who get COVID now may not be the same as they were 18 months to 2 years ago. So much has changed in terms of who’s getting vaccinated.” Heart failure patients who contract COVID-19 face outcomes that are “certainly much worse compared to” those without heart failure, she noted. “Our experience has been that the vast majority do return to normal, but there are patients that continue to complain of residual symptoms.”

For them, “the tricky part is oftentimes COVID-19 symptoms can overlap with heart failure syndrome,” she explained, so it’s necessary to “really take a deeper dive and understand what elicits the dyspnea and whether there are signs of congestion, which would go along more with heart failure.”

Spatz said it seems there’s a “spectrum” of conditions for COVID-19 patients who, after their acute infection, continue to have symptoms beyond 4 weeks or even 12 weeks. Frequently it’s hard to pinpoint the cause. At Yale, just 23% of 126 patients who presented with postacute sequelae of SARS-CoV-2 infection (PASC) to its long COVID clinic, known as the RECOVERY program, over a 16-month period had a specific cardiovascular diagnosis, Spatz and colleagues report on medRxiv.org. The rest they termed “cardiovascular PASC syndrome.”

Clinicians seeking a diagnosis first check for any damage from the coronary virus to the heart muscle and look for other known entities like myocarditis, cardiomyopathy, or ischemic disease, she explained. “But for the most part we do not find a mechanism or any kind of abnormality on our testing, and yet people are still having symptoms. So it’s a very frustrating experience for patients and for physicians.”

Based on what’s known from other viral illnesses, potential mechanisms for the nebulous array of symptoms could be some sort of disordered immune response to SARS-CoV-2, she explained. “And that’s a hard thing to test for because we don’t have a specific assay [for that]. . . . Physiologically people are experiencing changes in heart rate, changes in blood pressure, feeling like they can’t breathe, and all of that is [because] the body is out of sync.”

One common presentation is similar to postural orthostatic tachycardia syndrome (POTS), though rarely do patients meet all the criteria for that diagnosis. These POTS-like cases can benefit from a specialized rehabilitation program that focuses on hydration, physical exercise in the recumbent position, and breathing exercises. It’s not a “cure-all,” Spatz specified. “People are still suffering from cognitive issues. They may have other kinds of symptoms that are lingering. But it is a way for people to start feeling better.”

Research into COVID-19’s long-term impact is ongoing, including the RECOVER initiative from the National Institutes of Health. Mount Sinai investigators have published some data, and their work on imaging and cardiopulmonary testing continues, said Lala.

Spatz drew attention to the CDC-funded INSPIRE registry, for which she’s a principal investigator. INSPIRE is enrolling patients known to have symptoms of the viral disease before diagnosis and will compare between those who test positive and those who test negative. Having the latter as a control group will differentiate between the effects of COVID-19 illness versus the impact of the pandemic on society as a whole, she stressed. “Everyone’s living through a dystopian time with a lot of struggles, so the health of the general population is not well.”

We’re not out of the woods, needless to say. Anu Lala

While “we’ve made a huge leap in terms of our understanding, progress, and prevention,” said Lala, even in the acute setting there continue to be knowledge gaps, such as the optimal anticoagulation regimen and how best to handle patients with heart transplant who are already on immunosuppression when they contract SARS-CoV-2.

The likelihood is low that patients will develop new-onset heart failure in direct response to their COVID-19, Lala’s own research has found. But what’s the long-term prognosis of post-COVID patients who have evidence of fibrosis and scarring on imaging? “Are we looking at heart failure as a consequence down line? I don’t know,” she said.

Lala concluded: “So we’re not out of the woods, needless to say. I think we’ve learned a tremendous amount. And now in addition to continuing to understand the acute scenario, I think we have a large opportunity to understand the postacute sequelae scenario, as well.”