COMMENTARY

Mar 27, 2020 This Week in Cardiology Podcast

John M. Mandrola, MD

Disclosures

March 27, 2020

Please note that the text below is not a full transcript and has not been copyedited. For more insight and commentaryon these stories, subscribe to the This Week in Cardiology podcast.

In This Week’s Podcast

For the week ending March 20, 2020 John Mandrola, MD comments on the following news [and features] stories.

COVID-19

When I recorded last week there were 12,000 positive cases in the United States. Today there are 85,000 cases including 1200 deaths.

The stories from New York pierce your being—multiple medical schools allowing medical students to graduate early if they agree to take up positions in busy hospitals; calls for retired clinicians to come back; warnings that ICUs are on the brink of capacity; and reports of inadequate personal protective equipment.

Ethics

An incredibly stark document by Ezekiel Emanual and multiple other authors in The New England Journal of Medicine deserves mention. I call it stark because early stories from Italy and now some from Spain and perhaps soon in New York and other American cities tell the story of doctors making wrenching decisions about which patients will get ICU care.

Recommendations from the article:

  • Because maximizing benefits is paramount in a pandemic, Emanuel and colleagues believe that “removing a patient from a ventilator or an ICU bed to provide it to others in need is justifiable and that patients should be made aware of this possibility at admission."

  • Critical interventions such as testing, PPE, ICU beds, ventilators, therapeutics, and vaccines — should go first to front-line health care workers.

  • For patients with similar prognoses, equality should be invoked and put into place through random allocation, such as a lottery, rather than a first-come, first-served allocation process.

  • People who participate in research to prove the safety and effectiveness of vaccines and therapeutics should receive some priority for Covid-19 interventions.

  • "There should be no difference in allocating scarce resources between patients with Covid-19 and those with other medical conditions.

These are strong words, words that will surely spark debate, but also underscore the extraordinary times we are in.

Reference

Fair Allocation of Scarce Medical Resources in the Time of Covid-19

The Hydroxychloroquine/azithromycin Debacle

Fred Masoudi, a thoughtful electrophysiologist Tweeted yesterday: the reports of physicians stockpiling these medications for selves or family are atrocious—all should lose licenses because it is outrageously unethical and demonstrates an entirely deficient understanding of evidence-based medicine.

The French study that sparked the hype of hydroxychloroquine/azithromycin was not randomized; the endpoint was not clinical, it was viral load, and six of the 26 patients in the active arm were not followed-up, but not because they were lost. Three worsened and required ICU care, one died, and one stopped because of adverse effects.

If you are not on the front lines and want to do something helpful, tell people about this debacle. Tell your colleagues, right a blog, send a Tweet or Facebook post. Please stand against this nonsense.

In a NEJM editorial, Dr. Fauci and others outline lots of potential treatments for COVID-19.

Reference

Covid-19 — Navigating the Uncharted

COVID-19 and Angiotensin Drugs

The coronavirus uses the ACE2 receptor to gain access into cells. And this simple fact has led to numerous theories on ACE and ARBs making patients more susceptible. But then, there are studies showing that ACE and ARBS may be protective and some experts think possibly therapeutic. It’s complicated. But here I have to point you to a remarkable news column from veteran journalist Sue Hughes.

Bottom line: While the effect of this class of drug on clinical COVID-19 infections is unknown, what is known is that patients with severe hypertension or heart failure could easily decline if they stop the drugs.

Virtual ACC

We were supposed to be in Chicago this weekend for the annual American College of Cardiology meetins. Now, the organizers plan a virtual meeting. But now is not the time.

The ACC should postpone their virtual meeting and respect the people on the frontlines.

Medscape COVID-19 Conversation Board

Share your thoughts, feelings, and stories on the COVID-19 conversation page.

Comments

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