Long COVID and Inflammation: A Cardiologist's Expert View 

Rachel Pugh

Disclosures

August 12, 2020

When COVID hit London in mid-March 2020, Dr Ramzi Khamis found himself almost ovenight co-leading Imperial College's cardiology response to the pandemic. He had to find solutions to enable his teams to cope with adapting the service to deal with an influx of patients sick with the little-understood virus, whilst also maintaining the usual business of seeing people with heart attacks.

Dr Khamis is a consultant cardiologist at Imperial College Healthcare Trust with a passionate interest in inflammation, as well as being a leading researcher in the field of cardiovascular risk stratification. Alongside this, he has a parallel academic post as senior clinical lecturer in cardiology at the National Heart and Lung Institute.

 

His team's pre-COVID focus on looking at how the immune system links with atherosclerosis has provided valuable experience for setting goals for imminent ground-breaking research into understanding COVID-19's impact on the body.

Dr Khamis qualified in Bristol in 2000 and did most of his training in London. He completed his specialist and subspecialist training, as well as his PhD, at Imperial College and its affiliated hospitals.

He spoke to Medscape UK about the intense experience of working in a major London cardiology department when coronavirus hit.

Q&A

What has it has been like for you as a cardiologist suddenly having to co-lead your department 's response to this brand-new viral threat?

It was a very tough time. The week of March 15 was when I was asked to step up to managing our response to COVID. Very quickly we had to establish a command and control, set up different groups dedicated to areas of care such as PPE, IT systems, training, and assign consultant responsibilities, including new procedures for treating patients with heart attacks. Finding ways of separating patients with and without COVID was very difficult because we had to do it within days. One group was working on a COVID-protected zone and we were the first hospital in North West London to readmit elective cardiac patients. It was a very dynamic process of change.

 

At the same time I had to think about general management issues such as staff wellbeing and managing staff time off.

We were adamant from the start that COVID should not compromise heart attack services, but we got very worried at the beginning by a dramatic 30-50% reduction in people presenting with heart attacks. People were afraid and were simply staying at home. Through my involvement with the British Heart Foundation, we helped run a very successful education campaign to say that our doors were open. We did media interviews and people did come back. Now numbers are more or less back to pre-COVID levels.

What surprised you as you worked as a cardiologist during the pandemic?

During the peak I was more on the acute cardiology side, but what has been most interesting has been seeing patients post-COVID and the impact it has had on the cardiovascular system. The first 2 weeks we did not know that there was any cardiovascular impact, but then we realised that a certain percentage of patients were suffering from myocarditis, micro-infarction and some vasculitis. We started putting research proposals together but we could not really undertake large targeted research on the cardiac involvement during the peak, because government priorities were on research on anti-viral treatment, which was right.

What are your observations on 'long COVID'?

It is still very early days and much of the 'long COVID story' is still hypothesis. We really are at the beginning. But as we work we have been formulating hypotheses and recording all our observations in order to be able to investigate. What we really need is a cross-sectional observational study on 'long COVID' to try and characterise the syndrome.

One thing that surprises us now is to find that even with moderate COVID patients there is a number who find it difficult to recover. Their exercise tolerance takes a long time to return — 2 to 3 months or even longer. Some patients have residual palpitations and persistent tachycardia without any residual inflammation in the blood. You check the CRP and it's back to normal. A lot of the time a cardiac MRI is normal too, even though the patient is suffering from breathlessness or palpitations. Some of it is the body getting used to a reduced gas-oxygen transfer, but it does not explain everything. I wonder whether, because COVID affects the endothelium, these patients are exhibiting endothelial dysfunction. We plan to look into this.

We have a study ready to go if and when we get Peak 2, to look at a cardiac-directed anti-inflammatory agent, to see whether it can interrupt the action of cytokines causing myocarditis. There is historic and basic scientific evidence that using it may help.

What part does exercise play in COVID-19? 

Clearly if the patient is healthy and fit before the infection they will have a better chance of recovery, so there is a case to be made for pre-conditioning.

The big challenge is reconditioning post-COVID. It seems that the cytokine storm observed in some patients is acting to decondition the body, even though some of them were quite fit beforehand. It is a very slow process to relearn fitness, which needs to be done very carefully and under supervision. Employers need to understand that this is not like the flu — it can weaken the body significantly and it's taking weeks for some patients to return to normal activity. Biologically COVID behaves completely differently from flu, the sequelae are much more varied and the outcomes are clearly more dependent on co-morbidities.

Do we need to modify cardiology services in light of what you are seeing coming through your doors?

We have already done so at Imperial. Our post-COVID lung MDT and the cardio-immune clinic both include a cardiologist. We are organically modifying ourselves. COVID has taught us that we can be more fluid and dynamic. It's been an amazing professional experience. Everyone has been so agile in their reactions, with everyone helping in every way they can.

We also know that we can work well as a microenvironment. Under command and control we developed a system where 30 consultant cardiologists, 30 junior cardiologists and junior doctors across our radiology services could all meet on Zoom within an hour. In the first weeks we would have twice-weekly one-hour Zoom meetings for the consultants to plan the response. We also held a COVID cardiology conference on April 7 attended by 20,000 physicians and healthcare providers across the world to share the learning on COVID-19 and the heart. Everyone was really inventive.

Will what you have learned help you in the expected second wave? 

We have coped. We edited our protocols to adapt. We have used technology well to send one person to see a COVID patient and the rest would be online. Some of the things will be with us for a very long time and they will help us in running the service in the future. 

I think that the second wave will be easier to deal with because of what we have learned. Looking at other countries, even though the rate of infection is higher, the rate of mortality is now lower. I really hope that what we have learned will allow us to continue with elective services even at the height of a pandemic. We also have learned about the importance of supportive therapies like anticoagulants and steroids, as well as other measures that improve outcomes such as how to protect the heart and vascular system. The vaccine is the most important goal the scientific community needs to achieve by far. The hope has to be in that.

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