key: cord-1010258-zjamly35 authors: Vallabhajosyula, Saraschandra; Friedman, Paul A.; Bell, Malcolm R. title: Cardiovascular Health in the COVID-19 Era: A Call for Action and Education date: 2020-06-06 journal: Mayo Clin Proc DOI: 10.1016/j.mayocp.2020.05.031 sha: c984d6cb71531958e24dcc00cec65072330aa78f doc_id: 1010258 cord_uid: zjamly35 nan The Coronavirus Disease 2019 (COVID-19), a viral infectious disease caused by the severe acute respiratory syndrome coronavirus-2, has reached pandemic status worldwide. 1 COVID-19 primarily burdens the healthcare system by virtue of its high infectivity, respiratory compromise and need for critical care supplies, such as mechanical ventilators and hemodialysis units. As a consequence of these concerns, the United States Presidential guidelines on March 16, 2020 recommended stopping all elective procedures/surgeries and non-essential clinic visits, which was endorsed by multiple professional societies and bodies, including the Center for Medicare and Medicaid Services. 3 These recommendations have significant ramifications for elective, urgent and emergent cardiovascular conditions, which we seek to highlight in this perspective piece. Cardiovascular disease remains the leading cause of death worldwide in the contemporary era, and patients with cardiovascular disease are at additional risk during the pandemic. 2 Cardiovascular risk factors such as diabetes, hypertension, obesity and coronary artery disease have shown to be associated with worse outcomes in COVID-19. 2 Primary, secondary and tertiary prevention of cardiac disease continue to remain priorities in the COVID-19 era. 2, 4 Therefore, it is important to understand the implications of the current governmentmandated restrictions on clinical practice and the care of cardiovascular patients. Firstly, due to the concerns for the high infectious burden and the lack of established treatment, measures such as social distancing and 'stay-at-home' initiatives have been leading priorities for society. Due to prolonged periods of staying at home, there is a significant risk of P a g e | 4 Vallabhajosyula S et al. worsening dietary, lifestyle and exercise habits. 2 These may result in worsening of pre-existing cardiovascular disease, or the onset of new cardiovascular disease across all age-groups. 2 Therefore, there is an inherent risk of poorer control of chronic cardiovascular comorbidities which could lead to development of cardiac emergencies. Additionally, those patients with cardiovascular disease who develop COVID-19 infection have been observed to have a 10-fold increase in mortality. 2 Pre-existing hypertension has been noted to be associated with higher inhospital morbidity and mortality in COVID-19 infected patients. 4 Pre-clinical studies have noted renin-angiotensin-aldosterone system inhibitors to increase the angiotensin-converting enzyme-2, which is a functional receptor for the severe acute respiratory syndrome coronavirus-2. 5 However, no clear clinical associations have been noted in clinical studies or human subjects. 5 It is conceivable that patients with heart failure and hypertension may prematurely stop these groups of medications, placing themselves at a higher risk of worsening of their underlying cardiovascular disease. 4, 5 A recent report from the CVS Health Corp has shown a sharp decline in health care prescriptions, including for heart disease and diabetes, which might place patients at a higher risk of future events. 6 Second, due to the concerns for infectious risk, multiple studies have shown a decrease in the uptake of cardiovascular services, especially for medical emergencies. 7-9 Garcia et al. Vallabhajosyula S et al. delayed complications, mechanical sequelae of untreated STEMIs, and concerns for higher risk presentations. 9-11 COVID-19 infection has been associated with significantly higher rates of outof-hospital cardiac arrest. 12 Data from 15 Italian hospitals during the COVID-19 outbreak have shown a sharp decrease in acute coronary syndrome admissions, which was consistent across the STEMI, non-STEMI and unstable angina sub-groups. 13 Though the mechanisms are unclear, it is conceivable that in addition to the known respiratory complications, undetected acute coronary syndromes, cardiac arrhythmias, and higher rates of arterial/venous thrombus formation may contribute to this inexplicable rise in cardiac arrest rates. This was associated with a concomitant increase in out-of-hospital mortality that could not be fully attributable to COVID-19. 13 Third, cardiac procedures are traditionally classified as elective, urgent, and emergent. In reality, however, cardiac procedures are an intervention along the spectrum of the disease process that possesses the ability to significantly impact disease trajectories. For example, percutaneous coronary intervention in a patient with medically-refractory angina, aortic valve replacement in severe aortic stenosis or the use of cardiac resynchronization therapy in advanced heart failure are landmark events along the disease spectrum. However, in light of the recent call to cease all elective operations, there is a danger of oversimplification of procedural urgency. As a consequence, it is conceivable that many patients and health care teams might consider postponing these important procedures, thus leading to adverse patient outcomes (Figure 1) . 14 Lastly, the cardiovascular ramifications of non-cardiac diseases remain an under-explored avenue. For example, social distancing and loss of pre-existing social constructs adversely impacts mental health and emotional well-being. Patients with pulmonary, endocrine, neurologic, rheumatologic and oncologic diseases also experience cardiovascular dysfunction either by P a g e | 6 Vallabhajosyula S et al. virtue of their disease or therapy. The impact of these conditions on cardiovascular health, especially in the setting of a pandemic, needs further careful study. In light of the above data, it is understandable that the COVID-19 pandemic has caused significant and overwhelming fear in patients and their families. Due to concerns for contracting the infection, cardiovascular patients are avoiding medical contact at all costs, sometimes to their detriment. 11 In a recent analysis using the National Center for Health Statistics, deaths in the United States far exceeded that attributable to the pandemic. 15 Similar trends in excess mortality were noted in Italy. 13 Though the pandemic has resulted in high mortality thus far in the United States and worldwide, there has been a sharp rise in unrelated deaths. Importantly, it is highly probable that more people will die from cardiovascular disease than from COVID-19 in the United States in 2020. Three key components are essential to care in the time of COVID-19: modifications on health care campuses to permit safe in-person care, adoption of remote-care options, and patient education on strategies to maintain health and fitness, and to seek care immediately for urgent cardiovascular symptoms. Despite the increase in health care concerns surrounding the COVID-19 pandemic, our institution and others are striving to achieve a safe, effective and timely delivery of cardiovascular care. 1 Pre-visit phone calls and screening, point-of-care screening tools upon arrival, a universal masking policy, rapid rule-out testing, correct use of personal protective equipment and enhanced cleaning practices have mitigated infection risk to permit safe care on campus. P a g e | 7 Vallabhajosyula S et al. In-person care is supplemented by a number of established and novel remote care options including video consultations and remote smartphone-enabled technologies using traditional and novel artificial intelligence-supported tools. 2 The enhanced expanded coverage of telemedicine has provided access to these new tools in the health care armamentarium. 2 Particular established patient encounters, preventative cardiology consultations, and triage encounters can be rapidly and effectively performed in this manner. Remote evaluations may serve to identify the need for and timing of in person care, identify required testing in advance, and plan for expedited itineraries on campus. In addition, social distancing may provide patients and physicians the unique opportunity to utilize health care technology to monitor, communicate and follow-up with the health care team. 2 For medical emergencies, current protocols at our institution continue to emphasize primary percutaneous coronary intervention since it remains feasible due to a strong institutional triage system, and remains the preferred mode of acute reperfusion therapy in the United States. 1 Education is the third component of pandemic cardiovascular care. From a cardiovascular standpoint, it is imperative for patients, communities and health care providers to understand and emphasize that cardiac emergencies demand immediate care. In a recent statement, the European Society of Cardiology stressed to the community that the appeals to 'stay-at-home' do not apply to cardiac emergencies and requested that patients seek care as they have been previously. 11 In addition to cardiac emergencies, chronic cardiovascular conditions may worsen either relatedly or unrelated to the pandemic. Therefore, patients and physicians need to be cautious, vigilant and prepared. We recommend that physicians and patients act upon these important considerations (Figure 2) . Universal deferment of perceived elective procedures may place patients at an undue risk of future complications which may overwhelm the healthcare system once the social P a g e | 8 Vallabhajosyula S et al. distancing restrictions are lifted. Guidance documents from professional cardiovascular interventional and surgical societies have proposed a tiered system towards patients requiring procedures to prevent unwarranted complications from deferment secondary to the pandemic. 14 CONCLUSION COVID-19 is a global tragedy that remains an ongoing stressor on the health care system that will likely result in significant restructuring of health care practices both now and in the future. As it may persist into the foreseeable future, we must adapt healthcare delivery to continue to combat the number one killer of Americans -cardiovascular disease. Strategies to mitigate risk for in-person care, adoption of novel strategies to enable remote care, and robust education regarding prevention and immediate care for cardiovascular emergencies are the foundations of cardiovascular care during the pandemic, and beyond. ST-segment elevation, myocardial injury, and suspected or confirmed COVID-19 patients: diagnostic and treatment uncertainties Primary and secondary prevention of cardiovascular disease in the era of the coronavirus pandemic The President's coronavirus guidelines for America: 30 days to slow the spread Current perspectives on Coronavirus 2019 (COVID-19) and cardiovascular disease: A white paper by the JAHA editors Reninangiotensin-aldosterone system inhibitors in patients with Covid-19 CVS warns of surge in non-coronavirus health problems Reduction in ST-segment elevation cardiac catheterization laboratory activations in the United States during COVID-19 pandemic Management of acute myocardial infarction during the COVID-19 pandemic Collateral damage: medical care avoidance behavior among patients with acute coronary syndrome during the COVID-19 pandemic TCTMD: The Heartbeat Appeals to "stay at home" during COVID-19 do not apply to heart attacks Out-of-hospital cardiac arrest during the Covid-19 outbreak in Italy Reduced rate of hospital admissions for acs during Covid-19 Outbreak in Northern Italy Adult cardiac surgery during the COVID-19 pandemic: a tiered patient triage guidance statement deaths soared in early weeks of pandemic, far exceeding number attributed to covid-19