The Latest Update on COVID-19 and the Heart

John Whyte, MD, MPH; Deepak L. Bhatt, MD, MPH

Disclosures

June 04, 2020

Find the latest COVID-19 news and guidance in Medscape's Coronavirus Resource Center.

  • People having heart attacks, strokes, or symptoms of other heart problems are avoiding hospitals because they are scared of contracting COVID-19.

  • COVID-19 not only can worsen current cardiovascular disease but also can cause new heart issues.

  • COVID-19 appears to affect the heart and blood vessels by causing inflammation, which can lead to thrombosis.

  • NSAIDs have not been shown to treat COVID-19, and they can have serious side effects such as stomach and gastrointestinal bleeding, kidney damage, high blood pressure, and heart failure.

This transcript has been edited for clarity.

John Whyte, MD, MPH: You're watching Coronavirus in Context. I'm Dr John Whyte, chief medical officer at WebMD. Today we're going to talk more about how COVID-19 and the heart are related. Is there a direct impact on the heart, causing heart attacks, or do patients with heart disease simply need to be more cautious? I've invited Dr Deepak Bhatt, professor of cardiovascular medicine, to join us in the discussion today. Dr Bhatt, thanks for joining me.

Deepak L. Bhatt, MD, MPH: It's great to be here with you.

Whyte: Nine to 10 weeks ago, when we were talking about COVID and heart disease, we weren't so sure about the relationship. We kind of said it's a respiratory virus; it's all about the lungs. But now it seems like we're starting to think a little differently. What's the latest update about the relationship between COVID-19 and the cardiovascular system?

Bhatt: It's a terrific question, and there are many layers of connection with cardiovascular disease. The first one I'll start with isn't a biological one, but it's an important one. A lot of folks who are having heart attacks or worsening heart failure or strokes aren't even coming into the emergency department or the hospital, so that's been a real bad consequence of the COVID-19 pandemic, that people with non-COVID–related illnesses are actually getting worse care. And it's because, many times, they're just not showing up to the hospital, even though they probably know deep down inside that they should.

Whyte: Well, we scared them. We told them not to come in. And now we're saying, "Come back, call 911 if you're having chest pain."

Bhatt: Yes, so it's understandable, of course, that people would be worried about coming to the hospital and catching COVID and that sort of thing. On the other hand, probably in some respects now, hospitals are safer than going to the grocery store. That is, everyone's wearing a mask. There are lots of precautions being taken to prevent COVID transmission.

And regardless of what the risks might or might not be on a theoretical basis, if someone's having a heart attack or a stroke or really bad worsening of heart failure, those are things that are potentially life-threatening conditions. So it's always the right thing to go in. Certainly, right now hospitals are able to take care of those patients and take care of them well. So for people who have those conditions or think they might—and a lot of times you don't know until you call 911 and get evaluated—the right thing to do is still call 911 and get checked out.

Whyte: Have our thoughts changed, our understanding changed, about the relationship between COVID and the heart? Is there a direct impact in terms of the vascular system? Or is it still mostly an issue where folks need to be more cautious if they have heart disease?

Bhatt: Folks with heart disease should be cautious, should take all their medicine, should make sure they're not skipping their medicines. If anything, those things are even more important now. But as far as your question, is there a direct effect of COVID-19 on the heart, on the vasculature, I think we're learning that the answer is yes. And it's important that I say that we are still learning about that and all aspects of COVID-19.

So it's not a done deal, but it does seem like there are direct effects that can occur on the heart—for example, inflammation of the heart or myocarditis. That doesn't seem to be extremely common, but it does seem to occur. But more importantly, COVID does play into heart attacks to an extent, it does seem, by two different mechanisms. It does appear that COVID-19 promotes inflammation, broadly speaking. That can affect the lungs. That can affect the heart. That can affect the kidneys. That can affect the blood vessels. It can affect lots of different organs in the body.

A lot of times, where there's inflammation secondarily, thrombosis or blood clot formation can occur. It's that coupling of inflammation and thrombosis that actually causes a lot of the complications of COVID-19, whether it's the heart or the blood vessels.

I'm sure people have heard reports of strokes and increased rates of strokes in these patients, including in young people, as well as, of course, in older people, where heart disease might already be preexisting. So COVID-19 can play a role in worsening preexisting cardiovascular disease or causing just new problems.

Whyte: Yes. And you're editor-in-chief of the Harvard Health Letter. So I want to ask you, how are we doing in terms of communicating information to both physicians and patients?

Bhatt: With respect to COVID-19, as far as anything people might be hearing, don't try it at home. As far as therapies go, these are things that need to be proven in different clinical trials; vetted by physicians; vetted by regulatory agencies, in some cases; and then utilized.

It isn't the sort of condition or medications where people should just self-medicate, thinking they might be helping either prevent or treat COVID-19. That can actually be quite dangerous. As far as what we said about NSAIDs—nonsteroidal anti-inflammatory drugs—those can be useful in terms of short-term use for conditions like acute pain from, say, a bad knee or arthritis or things like that. But even in people without COVID-19, there's some risk with those sorts of medicines: stomach bleeding, gastrointestinal bleeding, is a risk, and they can hurt the kidneys sometimes. They can prompt elevations in blood pressure or prompt episodes of heart failure.

So there are all sorts of potential side effects that NSAIDs have just in general in anybody. Those risks are exacerbated in people who already have heart disease, are exacerbated with higher doses of NSAIDs with more chronic, around-the-clock use. So in general, with NSAIDs, you always want to use the lowest dose possible for the briefest period of time.

But with respect to COVID-19, right now there's no good evidence to suggest that NSAIDs would be helpful. There's some observational data suggesting maybe harm, but even that I wouldn't necessarily take too seriously. A lot of the studies and research that's been done to date in terms of medications and COVID-19 are the sort of lowest level of research, so-called observational research, which can sometimes provide insights. But it's not the gold standard of research, which is a randomized clinical trial. And that's what we really need to move this wheel forward.

And there are trials that are starting in a variety of different disease-modifying agents, things like anti-inflammatories, antithrombotics, of course drugs that target viruses and antiviral therapy. So, many things are ongoing. But until those trials are done, we don't want to jump the gun too soon; it could lead to all sorts of complications because no medicine is side effect–free.

Whyte: What about those patients who are hearing about increased blood clots, even in those patients who are on anticoagulants? What are your insights into that observation?

Bhatt: I think it's a real observation. We're seeing a lot of blood clotting in people with COVID-19. But what might not be apparent to many people is that we see lots of blood clotting in sick people in general. That is one of the leading causes of death out there generally speaking but includes in hospitalized patients—the pulmonary embolism, where a blood clot from the leg, a deep vein thrombosis, breaks off and a piece of blood clot goes to the lungs, which can lead to the lungs and heart collapsing, failing.

So that's a real problem already, pre-COVID. And now in COVID it seems to be even more common. Any really sick patient, hospitalized patient, even with influenza, is subject to have those complications, but the rates do seem a lot higher in COVID-19–positive patients. Again, I think it's that COVID-19 can make people sick. That can raise the risk of things like bad clots. But it also does seem to directly raise the risk of blood clotting, so-called thrombosis.

The real insider might be inflammation. There have already been studies that show that the endothelium, which is a cell lining or the cells lining the inner surface of blood vessels—actually the largest organ in the body if you look at it laid out—gets inflamed in COVID-19 patients. So that could be behind a lot of the problems we're seeing, including some of the very recent problems we've heard of described in children, which is quite worrisome.

Whyte: You've always been very active on the speaker circuit as a way of educating your fellow clinicians. Obviously, COVID-19 has canceled lots of national meetings and local meetings. What's the role of digital in helping to educate both the primary care physician and the specialist? Is it different?

Bhatt: I think that's a really important question, especially from WebMD. You all are involved with a lot of education of physicians and other healthcare providers and patients. I think things are going to change because of COVID-19. But I think there's the potential for some things to change for the better.

One of my fellows at Brigham and Women's Hospital, Wendy Wang, and I wrote a piece in Journal of Invasive Cardiology where we called COVID-19 "a force for unintended, but potentially beneficial, medical revolution." That is, we really think there are a lot of good things that can come out of how we learn and adapt to COVID-19 as a healthcare system, and that includes healthcare education.

Along those lines, there's another article I was involved with that was published in the European Heart Journal. It was a piece on how Twitter might actually be more useful for education and even for continuing medical education.

So I think there are a lot of possibilities now for us to reconsider how we've done things in the past. That includes education. For example, a lot more meetings in the future can be done remotely. What you and I are doing right now—we're not in the same room, but I think we're having an interesting conversation. At least from my end we're having an interesting conversation.

But in the future, why not have more medical meetings like this? It can cut down on travel costs, time away from work, time away from family. Yes, there's a social element if we were in the room together or if it were a large meeting, interacting with colleagues we haven't seen maybe in a year or two. I agree that there's that social element that may not be so easy to reproduce.

Whyte: Dr Bhatt, I want to thank you for sharing your insights.

Bhatt: Sure. It's been a pleasure speaking with you.

Whyte: And thank you for watching Coronavirus in Context.

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