Strategies For Risk Reduction and Management of Older Adults With Cardiovascular Disease During the COVID-19 Pandemic
Many older adults fearful of COVID-19 are strictly adherent to social isolation measures and may be avoiding routine medical care. Continued management of cardiac disease during the pandemic is essential as optimization of cardiovascular health may not only decrease the risk of a cardiac admission but potentially mitigate vulnerability if exposed to SARS-CoV-2.
Patients should be contacted to avoid canceling appointments and encouraged to reschedule via telehealth encounters when feasible. Older adults may have difficulty navigating audio-visual technology, so patients and families should be encouraged to familiarize themselves with a video platform to which they have access and feel comfortable using. Telephone visits should be maintained and will be reimbursed if patients cannot or do not wish to use video technology.
Encounters with noninfected older adults during the pandemic should focus on disease prevention and COVID-19 preparation. Older adults with cardiovascular disease are at risk for both severe presentation of COVID-19, and lack of adequate cardiovascular disease monitoring during the pandemic. Cardiologists can consider these practical management strategies to facilitate care.
- Safeguarding measures should be reiterated at every opportunity, and clinicians should utilize the teach-back method to ensure understanding. Clinicians who need to engage in direct patient care should strictly adhere to Centers for Disease Control and Prevention (CDC) guidelines, and consider taking additional precautions, e.g., avoiding direct encounters with high-risk older adults if there has been recent significant exposure despite a lack of symptoms.
- ACE-inhibitors, angiotensin-receptor blockers, mineralocorticoid receptor antagonists, and angiotensin receptor-neprilysin inhibitors should be continued in older adults, as in all cardiac patients, in the absence of contraindications, and statin therapy maintained or possibly added assuming absence of contraindications, according to ACC recommendations.
- The importance of maintaining nutrition, hydration and daily exercise despite social isolation measures should be emphasized.
- Older adults should be instructed to identify a healthy, low risk, trusted point of contact with whom physicians can maintain communication.
- All older adults should be strongly encouraged to prepare advance directives and clarify religious preferences prior to potential SARS-CoV-2 infection so treatment decisions that must be made at the time of potential illness are concordant with their goals.
COVID-19 disease management in older adults should be individualized. Older adults are heterogeneous with respect to health status and resiliency; chronologic age alone should not determine management strategy. Considerations include:
- Pharmacologic management for eligible older adults should follow guidelines outlined by the CDC. In particular, the efficacy of hydroxychloroquine and chloroquine remain unproven and optimally should be administered within clinical research protocols. Notably, however, QT prolongation risk increases in the setting of structural heart disease, electrolyte disturbances, hepatic/renal failure and concomitant QT-prolonging medications, which are all common among older adults, so precautionary measures as outlined by the ACC are strongly recommended.
- Patients should be informed that if hospitalized, recovery and access to post-acute care, may be challenging as they may suffer new dependencies/functional impairment, as well as be subject to strict isolation measures.
- Patients should be instructed to identify a caregiver to assist in recovery if sent home. Also they should prepare a means to maintain social connections (e.g., FaceTime, family chat rooms, etc.) to help ease the very emotionally challenging experience of recovering in isolation in a skilled nursing facility.
- Older adults should be encouraged to participate in clinical trials pertaining to COVID-19 management if feasible. Potential trials can be found here.
This article was authored by Nicole M. Orr, MD, FACC, and the Geriatric Cardiology Council.
Keywords: Aged, SARS Virus, Angiotensin Receptor Antagonists, Hydroxychloroquine, Mineralocorticoid Receptor Antagonists, Caregivers, Angiotensin-Converting Enzyme Inhibitors, COVID-19, Coronavirus, Coronavirus Infections, Neprilysin, Hydroxymethylglutaryl-CoA Reductase Inhibitors, Neprilysin, Chloroquine, Subacute Care, Social Isolation, Skilled Nursing Facilities, Cardiovascular Diseases
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