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Wear The Gown: Heart disease and the potential impact of the coronavirus

The underlying condition of heart disease could make the coronavirus harder to control.

SAN ANTONIO — When it comes to the novel coronavirus, people with underlying health conditions have a greater chance of experiencing complications if they catch the disease. In the latest installment of Wear The Gown, we tackle the issue of heart disease and the potential impact of coronavirus.

To answer your questions we turn to Dr. Dawn Hui, a cardiothoracic surgeon at the University Health System and UT Health San Antonio.

Why is heart disease a big risk factor if you contract COVID-19? 

Hui: There are two things. First of all, we know that patients with those diseases are more likely to contract COVID-19. We don’t really know the reasons underlying that but if that is the case. And the second thing is once they do contract the disease they have a more severe course and are more likely to have severe symptoms to require a ventilator and unfortunately they are less likely to survive the disease.

When patients contract COVID-19, we think of it as a respiratory illness primarily, but there are a lot of inflammatory effects that occur throughout the body. So patients with heart disease may not be as well equipped to handle the inflammatory stressors. 

In addition, the heart itself can develop inflammation leading to a condition we call myocarditis which literally means inflammation of the heart.

What can I do to boost my immune system so I'm better able to fight off COVID-19? 

Hui: There aren’t any recommendations primarily to boost the immune system other than what is generally recommended which is to eat a well-balanced heart healthy diet. If you have dietary restrictions and you can’t eat certain foods then there should be vitamins or supplements. 

The second thing is to continue your daily activities and get some level of exercise of course practicing social distancing guidelines with that. 

The third thing is patients who have diabetes are very prone to inflammatory processes so keeping very good control of blood sugars is important as well.

Fourth, it is important to stay current with the flu vaccine, and if your provider recommends it, a pneumococcal vaccine. These do not protect against the coronavirus, but they may protect against contracting other infectious diseases, particularly respiratory ones. At an individual level, it can keep people healthier. And from a public health perspective, the fewer people that have the flu, the greater the resources we can preserve for those with COVID-19

Some are concerned that heart patients taking ACE inhibitor medications are at risk for more severe cases of COVID-19. Should I stop taking that medication?  

Hui: There’s a lot of discussion and interest in whether or not ACE inhibitors are dangerous or not for COVID-19 patients. To start with, ACE ininhibitors are a class of medication that are very commonly prescribed to treat hypertension and heart failure, particularly in people with diabetes or chronic kidney disease. If you don't know whether you are on an ACE-inhibitor, you can look at the generic name of your medication. ACE-inhibitors end with the letters "pril" - some common ones are lisinopril, benazepril, enalapril, and so on.

At this time, based on the current evidence that we know, there is no evidence that ACE inhibitors cause worse outcomes in COVID-19. The medical societies recommend that people do NOT stop ACE inhibitors for people who are taking them; it's important for them to continue to take prescribed medications to treat their underlying conditions. If these conditions go untreated, it could in fact worsen a COVID-19 infection.

ACE inhibitors have a complex set of actions in the body, so even though there are theoretical reasons that ACE inhibitors could make people more prone to cardiac or lung injury, there are also reasons to think that it may actually be helpful in COVID-19 patients. There are certainly alternatives. One is a class called angiotensin receptor blockers or "ARBs." While ACE inhibitors and ARBs work in the same pathway, there was even less concern that ARBs would be dangerous in COVID-19. However, research is still needed for both medications. There are many other classes of medications that also treat hypertension.

If you would like to discuss alternatives to ACE-inhibitors or ARBs, speaking with your primary care doctor or cardiologist is an option. But there are no specific coronavirus-related reasons to stop these medications at this time.

We've heard treatment with the malaria drug hydroxychloroquine may be effective for COVID-19 patients but can be dangerous for heart patients. Why? 

Hui: Not all patients should reject hydroxychloroquine outright just on the basis of having heart disease, but they should certainly be evaluated fully as to whether it is wise to try that medication. The drug hydroxychloroquine has been recommended as a potential treatment and often as mentioned in the setting as a combination with azithromycin. 

Both of those drugs have the potential to cause abnormal heart rhythm‘s or we call arrhythmia specifically QT prolongation. We don’t have evidence whether the combination of these two drugs has even more risk of causing QT prolongation. So if a patient is being treated with these two drugs it should be in the setting of monitoring with continuous telemetry which is constantly monitoring the heart rhythm and rate with daily EKGs, they should be under the care of a cardiologist who would monitor this and decide on whether or not the treatment should be stopped if these arrhythmias should develop. 

A patient who is being treated with COVID-19 who has underlying heart condition should be under the care of a team of doctors including a cardiologist.

I was recently diagnosed with an enlarged heart, but can’t find a cardiologist who will see me. Has the novel coronavirus created a shortage of cardiologists to see traditional heart patients?

Hui: The answer to the question probably depends on the region of the country. In areas where there has been a surge and a great strain on the hospitals on the healthcare system it is possible that cardiologists are being deployed to take care of COVID-19 patients and priorities have shifted to taking care of the most ill patients. 

In areas where there hasn’t been a surge I don’t believe there is necessarily a shortage of cardiologists. 

I’m a heart patient and was enrolled in a rehabilitation program. Should I continue rehabilitation?

Hui: I think it would be a good idea to continue the rehab program especially for somebody with an underlying heart condition however that should be done within the guidelines of social distancing. So the rehab program itself should be conducting social distancing guidelines and the travel to and from the rehabilitation place should also adopt social distancing guidelines.

 I'm not familiar with whether we have programs or adopting telemedicine but that is another potential avenue for somebody to continue their program while minimizing their exposure and risk.

For more information about family health call (210)358-3045. You can also find the rest of Wear The Gown stories at WearTheGown.com.

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