Heart disease and Coronavirus: if you have one, it increases your chances of getting the other – or the severity of its impact on you

– and the two together are bad news

No organ has been disrupted by Coronavirus like the cardiovascular system.  This is because the heart and lungs work closely together to supply the body with essential oxygen.  Coronavirus not only disrupts this system, but it can also worsen the condition of patients with existing heart disease.  It can even cause heart disease for the first time in patients not known to have the condition previously.  

We will discuss all these, together with a summary of the European recommendations and how to take care of your heart during the pandemic.

Coronary heart disease (CHD) or Cardiovascular Disease (CVD) is the number one killer in the UK.  1 in 5 men and 1 in 7 women die from CHD in the UK, killing 80,000 people each year, with the death rates being highest in Scotland and the northern England, and lowest in southern England.

80% of Coronavirus cases are either asymptomatic or have mild symptoms and are likely to make a full recovery; 14% have moderate symptoms requiring hospital care; and 6% have severe disease requiring intensive unit care.

Having heart disease does not increase your chance of catching Coronavirus, but it does put you at risk of suffering severe Covid-19 disease and complications, if you do catch it.

Hypertension, high cholesterol, obesity and diabetes are risk factors for heart disease, while suffering a heart attack, having angioplasty (balloon procedure) or coronary artery bypass surgery all make you more likely to get severe Covid-19 than people who don’t have heart disease.

If you’re also over 60, or have lung or kidney disease, or if you’ve had open heart surgery in the past three months, you’re at particularly high risk.

Recent news backs this up

  • The British Heart Foundation has announced that 5,000 more known heart disease patients have died in England than would have been expected since the start of the pandemic and it urged patients to continue with their medical care.
  • Having a heart attack is well documented as a complication of Coronavirus infection. A study confirmed that 60% of Coronavirus patients have signs of myocarditis (inflammation of the heart muscle.)
  • Edinburgh University examined echocardiograms from more than 1,200 Coronavirus patients in 69 countries and found 55% of them have heart abnormalities, which were severe in 1 out of 7 cases.
  • In England, the number of patients attending A&E with possible heart attacks has declined by 50% since the beginning of March 2020.
  • In the US, patients attending emergency departments have declined by 25% for heart attacks, 10% for stroke, and 7% for high blood sugar.
  • Spain has reported a reduction in heart attack procedures from the last week in March 2020 compared with the period before the pandemic.
  • In April 2020, cardiologists announced that patients suffering heart attacks may put their lives at risk by not seeking immediate medical help.

The Covid-19 virus primarily infects the lungs, with a secondary negative effect on the heart and cardiovascular system.  Blood oxygen levels drop with severe lung damage, while blood pressure falls with systemic inflammation.  These factors cause the heart to pump harder and faster in order to meet body’s oxygen requirements.

This can obviously result in severe health disturbance, which is worse in the presence of other risk factors such as diabetes and hypertension.  Patients at highest risk include elderly and frail people, patients suffering from heart failure, cardiomyopathy and congenital cyanotic heart disease.

So far, there is no evidence that Coronavirus infects implanted cardiac devices such as pacemakers and cardioverter-defibrillators or causes infective endocarditis in those with artificial heart valves.

NHS services disrupted

Coronavirus has also had the effect of disrupting many services designed to help CVD/CHD patients.  These operations include:

  • Hyperacute services (cardiac catheter lab) for confirmed heart attacks, aiming to unblock the artery and restore blood supply to the heart muscle within a target time of 120 minutes from the onset of chest pain, in order to avoid heart muscle damage.
  • Acute services for urgent procedures such as pacemaker insertion.
  • Routine procedures such as heart valve replacement.
  • Chest pain clinics, which receive daily referrals from A&E and GPs, for early assessment to prevent and treat confirmed heart disease patients.

In general, fewer patients were diagnosed with heart disease during the pandemic, increasing the risk of heart attacks and deaths.  Indeed, studies confirmed a significant increase in cardiovascular mortality in the three months before and after the beginning of the pandemic, with hospitalisation and cardiac catheterisation activities correspondingly down.

The reduction in cardiac department activities is explained by the fact that patients avoided hospitals for fear of infection.  In the US, deaths at home have risen in areas hit hard by Covid-19.

Why are they not attending?

Coronavirus increases mortality in patients with heart disease, therefore patients avoid hospitals for fear of catching the infection.

High-risk CVD patients, such as those experiencing a heart attack, have been reluctant to seek help, resulting in a significant reduction in admissions for heart attacks in Europe and elsewhere and an increase in preventable death and disability.  (Patients also felt that online or phone consultations were insufficient to address their needs.)

Patients were also deterred by the safety measures applied by hospitals, who were asking for a detailed history of their exposure to Covid-19 and temperature checks, before they could attend their appointments.

Objective evidence from European and US registries suggests a 25-40% reduction in heart attack presentations during the outbreak, as well as delays in the response times of overloaded ambulance and emergency services, resulting in presentations too late to allow the patient to benefit from life-saving treatment.

In addition, the re-prioritisation of hospital resources has significantly decreased access to cardiovascular services and elective procedures, as well as leading to a drastic reduction in the availability of cardiac surgery.

Coronavirus cardiovascular collateral damage

Coronavirus can result in cardiovascular disease, because of the high risk of blood clotting associated with the virus, resulting in more acute cardiac events in patients with pre-existing heart disease, such suffering as a heart attack.

A report from China at the outset of the pandemic showed some patients presenting initially with cardiovascular symptoms, such as palpitations and chest tightness, rather than respiratory symptoms.

Analysis of all Covid-19 cases reported by China showed that the mortality rate in patients with no comorbidities was less than 1%, whereas for patients with CVD, it was more than 10% (compared with 7% for diabetes, 6% for hypertension, 6% for chronic respiratory disease and 6% for cancer.)

A study in northern Italy reported a significantly higher mortality rate for cardiac patients compared with non-cardiac patients (35.8% to 15.2%.)

Covid-19 seems to be associated with the development of blood clots.  Studies from the Netherlands and France suggest that clots arise in 20–30% of critically ill Coronavirus patients.  Physicians in New York reported that blood clots and heart attacks are occurring even in healthy young people with no previous risk factors and sometimes no other symptoms of the virus.

The European Society of Cardiology confirmed that cardiovascular risk factors and heart disease increase the risk of poor outcomes from Coronavirus.  And the (sort of) reverse is also true: Covid-19 is considered a risk factor for the development of cardiovascular disease.

If you have one, it increases your chances of getting the other or its impact being severe – and the two together are bad news.

The European Society of Cardiology recommendations

The general recommendations include ensuring that cardiac emergencies are treated through completely separate pathways to those being used for patients with Covid, in order to reduce risk of infections.

It is important to resume clinical activity for the prevention, early diagnosis and treatment of cardiac cases in a safe environment, since delaying visits and procedures can lead to more heart damage.  This should also reduce the waiting times for several elective procedures.  More research is needed to support clinical decisions for the more effective treatment of Covid-19 patients with pre-existing heart disease, and of those who develop heart disease as a complication of Coronavirus infection.

For medics: heart diagnostic criteria in Coronavirus infections

The diagnostic criteria for a heart attack are an ECG suggestive of MI, high hs-TnI or hs-TnT level, high BNP >400.  No specific ECG changes have been described in Coronavirus infection.  B Natriuretic Peptide (BNP) – the diagnostic marker for heart attack and heart failure – may be elevated in Coronavirus patients.

Marked elevation of cardiac troponin (also diagnostic for heart attack) has been used to indicate poor prognosis in Coronavirus cases.  Mild elevations of cardiac markers do not need further investigation, as these may be due to pre-existing cardiac conditions or acute illness.

Treatment of heart attacks during Coronavirus

The main procedure – to open up the artery – primary percutaneous coronary intervention (PPCI) should be completed within a maximum target of 120 minutes.  (The guidelines allow going back to the old treatment, fibrinolysis, or dissolving the clot using drugs, as the first line of treatment if this target time is likely to be breached.)

Performing some procedures at the bedside can be considered, since transporting patients to the catheterisation laboratory carries the risk of infection, e.g., procedures like intra-aortic balloon pump insertion.

Tele-health (online or phone consultations) should be used as much as possible for the follow-up of patients with cardiac conditions.  Patients with chronic coronary syndromes should continue to take aspirin for secondary prevention.

Treatment for acute heart failure should be the same for all patients, regardless of infection status.  Patients are advised to continue taking their ACE inhibitors pill.

Hypertensive patients admitted with Coronavirus should have their plasma potassium monitored, since hypokalaemia (low potassium) increases the risk of cardiac arrhythmia.  Patients treated with hydroxychloroquine or azithromycin in combination are at high risk of arrhythmia (prolonged QT interval or torsade de pointes.)

Consider rate control treatment in patients with atrial fibrillation or flutter who are haemodynamically stable.  In haemodynamic instability, intravenous amiodarone is the antiarrhythmic medication of choice.  However, there is a risk of QT prolongation if used in combination with hydroxychloroquine or azithromycin.

Despite original concerns that angiotensin-converting enzyme inhibitors or angiotensin receptor blockers (ARBs) might increase susceptibility to severe infection, two large studies resolved these concerns.  Therefore, these medications should not be discontinued unless the patient acutely deteriorates.

Image source: https://theconversation.com/who-needs-to-be-in-an-icu-its-hard-for-doctors-to-tell-56728

Other fall-out from Coronavirus

The restricted movement of people, together with heightened stress levels, during the pandemic has resulted in increased rates of obesity, diabetes and associated metabolic disease and an increase in cardiovascular mortality.

Social distancing, the absence of positive relationships and the reduced chance of interaction with other people have been identified as major risk factors for cardiovascular mortality.  A recent meta-analysis including a total of 180,000 participants demonstrated that the risk for ischaemic heart disease and stroke increased by 29% and 32%, respectively, among lonely and socially isolated people.

I feel the problem is greater than has been documented.  Since life is not going to be the same after Covid-19, I am sure we are going to have another pandemic – this one of obesity and chronic diseases, parallel to the Coronavirus pandemic.  This is an interesting topic for the next blog – in the very near future.

How to take care of your heart during the pandemic

Lockdown and the restriction of movement, together with junk food, severe stress and lack of physical activity, may result in the development of cardiovascular risk factors such as obesity, hypertension, high cholesterol and diabetes.  These may combine to produce heart disease.  So, it is crucial to adopt a healthy lifestyle during the pandemic.

Heart rate up: you can follow the WHO recommendations of 150 minutes of moderate effort or 75 minutes of intense physical effort per week or both.  You are advised to take short breaks; use a standing work desk and follow the exercise classes available online.

Eat real: eat whole real food of fruits and vegetables, beans and legumes, healthy fats (nuts, seeds, oily fish, olive and coconut oil), include good sources of protein, such as caught fish, organic chicken and grass-fed meat.  Food should be rich in fibre, vitamins and minerals, essential ingredients of health.  Stay well hydrated, take adequate amounts of water (8 glasses, equivalent to 2 litres a day.)

Aim for eight: try to get 7 to 8 hours of deep, uninterrupted, restful sleep to feel refreshed in the morning.  Early to bed and early to rise.  Observe sleep hygiene – come off all screens two hours before bedtime.  Resistant carbohydrates in your evening meal to avoid sleep disturbance at night.  Maintain your circadian rhythm with good sun exposure, as this also helps the body to make more vitamin D – vital in fighting off Covid-19.

Relate regularly: maintain your social network; keep relationships healthy with unconditional love, forgiveness and gratitude.  Continue to have regular contact with family and friends using various meeting platforms.

Toxicity down: limit the information you absorb about the pandemic to only a few reliable sources.  Adopt stress reliving techniques, such as deep (pranayama) breathing, meditation and prayers, listen to humour and your favourite relaxing music every day.  Epsom salt baths in the evening are good for relaxation, and to help sleep; avoid toxic coping strategies, such as alcohol and drugs.

Stay safe, my friends, and, as always, if you have any questions to ask or experiences to share, please feel free, and I will endeavour to answer as soon as possible.  Remember the best way to stay up to date and never miss anything is to sign up for our newsletter to get the latest information and support.


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