COVID-19 Can Increase Risks for Cardiovascular Events

The novel coronavirus (COVID-19) emerged in Wuhan, China, in December 2019 and rapidly evolved to a worldwide pandemic within 3 months.^1,2

The number of confirmed cases of COVID-19 is rising in the United States by the hour. By the first week of May 2020, more than 1 million Americans had been infected with COVID-19, leading to more than 60,000 deaths.^2,3Statistical models predict that the COVID-19 pandemic is expected to persist for months, showing few signs of abating until targeted medications for treatment and/or a vaccine become available.⁴

COVID-19 is an infectious respiratory disease caused by a newly discovered pathogen, SARS-CoV2, a novel ribonucleic acid (RNA)-dependent RNA polymerase beta coronavirus that has not previously infected humans, contributing to the lack of immunity to the sometimes deadly virus.^5,6The COVID-19 virus mainly affects the lungs but has also been associated with exacerbating underlying cardiovascular problems. Like previous endemic viruses, such as Middle East respiratory syndrome (MERS) and severe acute respiratory syndrome (SARS) and infections, COVID-19 has been linked to the inflammation of the heart muscle, increasing the risk for myocardial infarction and rapid onset heart failure.^5,7,8Viruses such as COVID-19 have also been associated with causing problems with coagulation and are known to destabilize plaques leading to thrombosis or intraplaque rupture and stroke.^6,9Early data also suggest that patients infected with COVID-19 who are immunocompromised or older or who have comorbid conditions such as chronic lung disease or diabetes may be at higher risk for developing severe complications and death.⁸⁹

In the rapidly changing landscape surrounding the COVID-19 pandemic, it is imperative that health care providers remain abreast of current recommendations from reliable sources. The American Colleges of Cardiology (ACC), American Heart Association (AHA), and CDC, among other science-based organizations, regularly update guidelines for prevention and treatment for patients with underlying chronic conditions.

With more than 100 million Americans living with some form of cardiovascular disease (CVD), including heart failure, hypertension, and stroke, CVD remains the leading cause of death in the United States.¹⁰These alarming statistics underscore the need to pay close attention to those with CVD, as they are among the most vulnerable in the global battle against COVID-19.

Strategies that patients with CVD can use to avoid infection and transmission of COVID-19 and maintain wellness include:

· Avoid touching the eyes, mouth, and nose.

· Call 911 if experiencing chest pain, shortness of breath, or other warning signs of a heart attack or stroke.

· Contact a health provider immediately if experiencing, fatigue, fever and a sore throat.

· Continue social distancing, and stay at home as much as possible.

· Cover coughs and sneezes with a tissue, and then throw it away.

· Create a list of emergency contacts, and keep it an any easy-to-find place.

· Follow the recommended diet as closely as possible.

· Keep home surfaces clean.

· Order delivery services for essential items, such as food and medicine, to avoid social contact and reduce exposure.

· Remain as active as possible by doing at-home exercises that can be physically tolerated.

· Stay up to date with all vaccinations, including flu and pneumonia vaccines.

· Stock up on prescribed medications by renew refilling and obtaining a 90-day supply if the health plan allows to ensure a sufficient supply for an extended time period.

· Use telehealth options by messaging, phone, or videoconferencing for visits with health care providers, if possible.

· Wash hands frequently with soap and water for at least 20 seconds.

· Wear a face cloth covering or mask when out in public places.

Providers should keep the following in mind when it comes to managing CVD patients while preventing and treating patients the COVID-19 infections:

· The ACC bulletin recommends that patients with CVD stay up to date with vaccinations, including the influenza and pneumococcal vaccines.

· As COVID-19 information changes hourly, ACC, AHA, and CDC guidelines are being updated regularly to guide health care providers in prevention and treatment.

· Morbidity and mortality increase significantly with age, with early data suggesting an increase of 8% among those aged 70 to 79 years and 15% in patients older than 80 years.

· More than 80% of patients experience mild to moderate respiratory symptoms and recover without intensive medical intervention. However, up to 50% of those with serious complications have an underlying condition.

· Patients with underlying CVD have a higher risk of contracting the virus and a worse prognosis, so advise them of that risk and encourage additional precautions in accordance with CDC guidelines.

· Quickly identify and isolate patients with COVID-19 symptoms from other patients, including in the ambulatory setting.

· Substitute telehealth or telephonic visits for in-person routine visits for stable CVD patients to avoid possible nosocomial transmission of the COVID-19 infection.

· Triage COVID-19 patients according to underlying cardiovascular, diabetic, oncological, respiratory, renal, or other comorbid conditions for prioritized treatment.

To best serve patients, health care providers on the frontlines must also protect themselves. ACC and CDC guidelines recommend the use of gloves, masks, and other personal protective equipment.¹¹Frequent handwashing and disinfection of cellular phones, computers, other devices, stethoscopes, and surfaces should also be exercised with great discipline.¹¹

Conclusion

Although much remains unknown about COVID-19, previous coronaviruses, such as MERS and SARS, offer insights into understanding the complications and risks.^6,8,11It is well understood that this novel virus can increase the risks for cardiovascular events, especially among patients with underlying chronic conditions.^6,8,9To further mitigate the spread of COVID-19, it is imperative that health care providers reinforce the general prevention guidelines, in addition to ACC and AHA recommendations for patients with CVD.⁸

Diana Baptiste, DNP, RN, CNE, is an assistant professor of nursing at Johns Hopkins University School of Nursing in Baltimore, Maryland, teaching across all levels of the graduate pre-licensure nursing program, who specializes in cardiovascular prevention and health care among high-risk populations.

Susan R. Giscombe, DNP, MS, FNP-BC, NE, is a family nurse practitioner specializing in cardiovascular prevention and urgent care, who teaches in the advanced practice nursing programs at the Johns Hopkins University School of Nursing.

References

1. World Health Organization. Coronavirus. who.int/health-topics/coronavirus#tab=tab_1. Accessed March 30, 2020.

2. CDC. Coronavirus (COVID-19). hcdc.gov/coronavirus/2019-nCoV/index.html. Accessed March 31, 2020.

3. Johns Hopkins University & Medicine. Coronavirus COVID-19 global cases by the Center for Systems Science and Engineering (CSSE) at Johns Hopkins University (JHU). coronavirus.jhu.edu/map.html. Accessed April 1, 2020.

4. COVID-19 Projections. Institute for Health Metrics and Evaluation. covid19.healthdata.org/projections. Accessed April 1, 2020.

5. Zhou P, Yang XL, Wang XG, et al. A pneumonia outbreak associated with a new coronavirus of probable bat origin.Nature.2020;579(7798):270-273. doi: 10.1038/s41586-020-2012-7.

6. Xiong TY, Redwood S, Prendergast B, Chen M. Coronaviruses and the cardiovascular system: acute and long-term implications.Eur Heart J.2020. 2020. doi: 10.1093/eurheartj/ehaa231.

7. Wu Z, McGoogan JM. Characteristics of and important lessons from the coronavirus disease 2019 (COVID-19) outbreak in China: summary of a report of 72314 cases from the Chinese Center for Disease Control and Prevention.Jama.2020. doi: 10.1001/jama.2020.2648.

8. Sanchez E. Coronavirus precautions for patients, others facing higher risks.American HeartAssociation.hheart.org/en/around-the-aha/coronavirus-precautions-for-patients-others-facing-higher-risks.Updated April 15, 2020. Accessed March 28, 2020.

9. Li B, Yang J, Zhao F, et al. Prevalence and impact of cardiovascular metabolic diseases on COVID-19 in China.Clin Res Cardiol.2020;109(5):531-538. doi: 10.1007/s00392-020-01626-9.

10. Benjamin EJ, Muntner P, Alonso A, et al. Heart Disease and Stroke Statistics-2019 Update: A Report From the American Heart Association.Circulation.2019;139(10):e56-e528. doi: 10.1161/CIR.0000000000000659.

11. COVID-19 clinical cuidance for the cardiovascular care team. American College of Cardiology. acc.org/~/media/665AFA1E710B4B3293138D14BE8D1213.pdf. Accessed May 3, 2020.