COMMENTARY

What UK Cardiologists Need to Know About COVID-19

Prof Mamas Mamas

Disclosures

March 20, 2020

This transcript has been edited for clarity.

Hi. My name is Mamas Mamas. I'm professor of cardiology based at Keele University.

Today on Medscape UK we're going to talk about COVID-19 and the impact in patients with cardiovascular disease and also its impact on us as a profession of cardiologists and healthcare professionals working within the cardiovascular space.

So, what is COVID-19? Well, in December 2019, there was an outbreak of pneumonia caused by a novel coronavirus occurring in Wuhan in the Hubei Province, which has rapidly spread throughout China and the world, resulting in the pandemic with over a quarter of a million patients infected, and over 9000 patients that have died from COVID-19.

Cardiac Patients' Risk

COVID-19 can have cardiovascular events in patients. Certainly looking at the data mortality rates of 10% in patients with cardiovascular disease have been reported and 7% in patients with diabetes, and looking at the prevalence of cardiovascular disease in patients that have passed away, it can be as high as 50% in many of the case series with the strongest prevalence of risk factors including hypertension and diabetes.

So very much patients with cardiovascular disease seem to be particularly susceptible from a COVID-19 perspective.

Molecular Reasons

Secondly, there are molecular reasons why the COVID-19 virus may impact on cardiovascular health in patients. So, it's been shown that the angiotensin II receptor found both in the heart but also in lung tissue and alveolar cells, is a receptor for the COVID-19 virus. And there have been concerns that use of angiotensin II receptor antagonists or ACE inhibitors may increase the expression of the ACE II receptor and therefore increase patient susceptibility to COVID-19 infection, and there has been quite a debate around whether we should be discontinuing ACE inhibitors in this at-risk group of patients.

I think guidelines from the European Society of Hypertension, from the ACC [American College of Cardiology], from the European Society of Cardiology are very much suggesting that we should continue ACE inhibitors in these patients, because certainly, in at-risk patients such as heart failure patients and so forth, discontinuing these medications may have a prognostic impact on our patients.

Impact on Services

I think now, COVID-19 virus is clearly going to have a major impact on our services that we provide.

We've seen this from data coming from China and from Italy, that healthcare resources are overwhelmed by the number of patients, and so we're going to have to really restructure the way that we work.

I think first and foremost, one has to think about what is safest for patients. I think in this environment, certainly admitting patients to hospital or seeing patients in the outpatient capacity is probably inappropriate. And so if your hospital trust hasn't made arrangements, I think they really should do.

Certainly in my trust, we've cancelled all elective work. We've cancelled all outpatient work, but we're now following patients up through telephone consultations or through telemedicine. I think this is much more effective and much safer for patients, rather than sitting in large waiting rooms of other patients with the potential for vectors and infections.

I also think that we have to think about how we are going to arrange our acute services. Certainly, the COVID-19 virus can increase the risk of cardiac decompensation. And in the past, so the SARS-MERS virus, again, that showed increases in the risk of ACS in patients, there was increase in the risk of acute coronary syndrome, heart failure decompensation, and so forth and I'm sure that will be the same for the coronavirus.

Interestingly, in small case series, for example from Wang et al, up to 7% of patients admitted to their unit had elevated biomarkers and this may represent type two MI [myocardial infarction] or myocarditis.

Other series have also shown that later, for example, during intubation and the risk of immune dysregulation, cytokine storm, then myocarditis can be much more prevalent, and increases in biomarkers have been shown to occur in up to 50% of patients.

So, going back to acute care of patients with cardiovascular disease, what should we be doing?

Well, I think first and foremost, we need to be thinking about developing protocols.

Certainly in the United Kingdom, for primary PCI [percutaneous coronary intervention] it's very much business as usual, and we are continuing to offer a primary PCI service. But as staff sickness takes hold as there are bed pressures, this may need to be reconsidered, and so certainly the Chinese have published their experience using thrombolysis and many of the protocols that I've seen on social media coming from the US involve thrombolysis.

I think, from the NHS perspective, we should refresh ourselves with protocols around thrombolysis. Certainly I haven't thrombolysed anyone for many years. And we need to make sure that we actually have thrombolytics in the hospital and so forth.

In terms of other acute coronary syndromes, I think the mainstay of treatment will be medical treatment. I think it's important to get patients out of hospital as soon as possible to reduce the risk of infection. I think we will have to retain capacity for invasive management of these patients, but these are going to be high-risk patients: patients with ongoing chest pain, patients with dynamic ECG changes with very large troponin rises and, in my unit, we've decided patients with a GRACE [Global Registry of Acute Coronary Events] score of 140. But before we transfer any patient for cardiac catheterisation then the team has to discuss with the interventional cardiologist.

And so certainly, I think it's important to think about the sort of protocols that you'll be doing in your unit and cascading these protocols to centres outside of the unit.

Protective Gear

Finally, the other important issue is staff protection. We have seen in China in Italy and other places that up to 20% of the infections are of health care professionals, and up to 10% of deaths have been healthcare professionals in some series.

I think in these times of challenges, particularly in getting FFP-3 masks, I think it's important to have protocols in place about who exactly and in what situation people will use these masks, and to try to enhance delivery of these masks.

Certainly in primary PCI, it's important to consider whether what you have is a type 2 MI or a myocarditis rather than a STEMI [ST-elevation MI], and have a low threshold for using masks on patients and considering the use of FFP-3 masks on staff.

I think this is going to be a very challenging time for the NHS. I think we're going to have to adapt the way we work. I think we're all going to have to work outside of our comfort zones. Certainly in my trust there was a meeting in which we were told that we may have to help in A&E and in a general medicine capacity.

So I think this is a great challenge for us.

Let me know what you think. Thank you for joining us on Medscape UK and keep safe.

You can follow Mamas Mamas on Twitter

Editor's note, 24th March 2020: This article was updated to correct transcription errors.

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