Introduction

The direct medical and financial effects of the Coronavirus disease 2019 (COVID-19) pandemic have been staggering as healthcare systems and clinicians have risen to the challenge of caring for large numbers of infected patients. To curb viral transmission, many outpatient clinics and pharmacies have limited hours and in-person availabilities. While the implications of these changes are far-reaching across the population, patients with cardiovascular diseases (CVD) are of particular concern for increased morbidity and mortality due to direct exposure to COVID-19 and indirectly from the interruptions in care.

The recent statement from the American Society for Preventive Cardiology provides several recommendations on how clinicians can continue outpatient care and mitigate effects from lapses in health care.¹ Here we summarize and discuss those recommendations.

Impact of Comorbidities on COVID-19 Disease

Patients with pre-existing comorbidities, particularly those with CVD, who become infected with COVID-19 appear to have more severe courses and worse outcomes. Patients with diabetes seem to have a higher risk of severe pneumonia, increases in inflammation, and hypercoagulability compared to patients without comorbidities. Similarly, those with hypertension show increased risk of severe infection.^2,3

Patients infected with COVID-19 who have CVD have an estimated mortality rate of 10.5%, while those with diabetes have a rate of 7.3%, and those with hypertension a rate of 6.0% compared to an estimated general mortality rate of 3.8%.^4,5 Additionally, of the patients who are infected with COVID-19, high rates of cardiac arrhythmias have been reported. Of 138 patients in a Chinese cohort, 16.7% experienced new onset arrhythmia.⁶ Rates of arrhythmias were higher in patients admitted to the intensive care unit compared to ones requiring lower level of care (44.4% vs. 6.9%). A minority of patients have also developed other cardiovascular syndromes including cardiogenic shock, acute myocardial injury, atherosclerotic plaque rupture, and heart failure.⁷

Many patients with CVD, diabetes, or hypertension are also on angiotensin-converting enzyme inhibitors (ACEIs), which upregulates the transmembrane enzyme angiotensin-converting enzyme 2 (ACE2). The SARS-CoV-2 virus was found to utilize ACE2 for cellular internalization, which created some concern about the use of ACEIs and may have inadvertently led some patients to discontinue their use of ACEIs.⁸ Alternatively, some have hypothesized protective effects of ACEIs for both disease severity and mortality.⁹ Given the lack of clinical data to support the harmful effects of ACEIs, and substantiated evidence of effectiveness of ACEIs in management of hypertension and heart failure, all major societies recommend continuing ACEI or angiotensin receptor blocker (ARB) therapy in patients with COVID-19.

Challenges in Continuity of Care and Outpatient Management

The effects of the COVID-19 pandemic have had far reaching implications beyond those who have the disease. Admissions for acute coronary syndromes, decompensated heart failure, stroke, and ST-segment elevation myocardial infarction catheter lab activations have all decreased.^10,11 The diminished admissions are perhaps in part due to patient reluctance to be hospitalized and guidance from health officials to stay at home. It is critical that healthcare workers educate patients not to delay seeking care when they are experiencing concerning symptoms. Similarly, efforts to provide quality medical care while maintaining social distancing practices have created unique challenges including maintaining rapport through video clinic visits, cardiac rehabilitation opportunities, and medication availability and ensuring care for patients without technologic access.

There are also specific populations where these challenges are having a greater impact including those with lower socioeconomic status or living in rural areas. Access to medication is also especially difficult for elderly patients who are advised to stay home.

Strategies for Improvement

While the COVID-19 pandemic has caused significant changes to our healthcare delivery system, there are many opportunities to mitigate CVD progression and improve health in our society. Clinicians across the country have continued seeing their outpatients in the era of social distancing via telemedicine visits. Telemedicine includes communication between patients and clinicians using audiovisual means without specifying the specific platform used. Dr. Athena Poppas et al. state that "telehealth is in some ways a return to the days of personal home visits."¹² Previously, the Department of Health and Human Services (HHS) had limitations on reimbursement, which stifled widespread use of this modality. However, during the COVID-19 pandemic, HHS has expanded reimbursement for telemedicine visits for all patients via phone or video call to ensure maximum uptake.¹³ As of March 30, 2020, it is estimated that approximately 75% of all outpatient cardiology encounters moved to telehealth.¹⁴

Cardiac rehabilitation (CR) is a potential opportunity for telehealth delivery (called home-based cardiac rehabilitation or HBCR) to decrease the potential lapse of CR that patients experience during the pandemic but also to increase access to this historically underutilized program. However, HBCR currently lacks reimbursement and there is a need for HBCR to advocate for increased reimbursement for sustainability outside of research settings.¹⁵

Telemedicine can be more effective utilizing remote patient monitoring (RPM) systems, where patients track and record their own data and collect digital biomarkers outside clinic/hospital such as vital signs, heart rhythm, glucose, or weight. Further development of such systems via user-centered design could enhance patient engagement in their care.

There are also creative ways to improve access and adherence to medications during this time. There needs to be removal of barriers to providing appropriate medications including prior authorizations and repeat laboratory tests or approval. Additionally, once patients have their medications, the full care team of nurses and pharmacists can, in their various capacities, call and remind patients, refill medications, and inquire about possible side effects with patients. In fact, the team-based care delivery has potential even outside of medication adherence. Since many primary care providers are being reassigned to inpatient units, there is a vacancy for the care of chronic diseases for outpatients. Carter et al. found that team-based care, with pharmacists and nurses guiding treatment, was associated with improved blood pressure (BP) control.¹⁶

Coping with Stress or Anxiety and Maintaining Lifestyle Habits

Social distancing has made it more challenging to maintain relationships. When compounded with the pandemic, this may exacerbate mental illnesses such as anxiety and depression. High perceived stress has been associated with a moderately increased risk of incident coronary heart disease.¹⁷ Increased stress levels have also been associated with dietary indiscretion and rising tobacco use.^18,19 Additionally, increasing stay-at-home recommendations and closures of public gyms have made it more difficult to maintain physical activity.

Healthcare providers can continue to promote mental and physical health throughout the pandemic. To ameliorate psychological stressors, patients can be encouraged to stay connected with their loved ones via technology. Patients can be counseled on at-home exercises and healthy diet recommendations to improve their cardiovascular health. Lastly, patients' tobacco habits should be re-visited at every appointment and appropriately directed to online resources, nicotine replacement therapies, and behavioral interventions.

Conclusion

The COVID-19 pandemic has drastically impacted both acute and chronic cardiovascular illnesses. If patients are unable to receive their regular healthcare, the pandemic toll will grow significantly as previously avoidable diseases develop. Healthcare providers are charged with adapting to the challenges to maintain continuity of care for their patients. Since the pandemic has started, there have been incredible acts of flexibility and creativity to maintain healthcare delivery to patients. By continuing to improve on such ideas and adapting them to individual practices, the impact of this pandemic on patients with CVD will be minimized.

References

1. Khera A, Baum SJ, Gluckman TJ,et al. Continuity of care and outpatient management for patients with and at high risk for cardiovascular disease during the COVID-19 pandemic: a scientific statement from the American Society for Preventive Cardiology. American Journal of Preventive Cardiology 2020;Mar 1 [Epub ahead of print].
2. Guo W, Li M, Dong Y, et al. Diabetes is a risk factor for the progression and prognosis of COVID-19. Diabetes Metab Res Rev 2020;Mar 31 [Epub ahead of print].
3. Lippi G, Wong J, Henry BM. Hypertension and its severity or mortality in Coronavirus Disease 2019: a pooled analysis. Pol Arch Intern Med 2020;130:304-9.
4. Wu Z, McGoogan JM. Characteristics of and important lessons from the Coronavirus Disease 2019 (COVID-19) outbreak in China: summary of a report of 72314 cases from the Chinese Center for Disease Control and Prevention. JAMA 2020;Feb 24 [Epub ahead of print].
5. CDC COVID-19 Reponse Team. Preliminary Estimates of the Prevalence of Selected Underlying Health Conditions Among Patients with Coronavirus Disease 2019 — United States, February 12–March 28, 2020. MMWR Morb Mortal Wkly Rep 2020;69:382–6.
6. Wang D, Hu B, Hu C, et al. Clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus-infected pneumonia in Wuhan, China. JAMA 2020;Feb 7 [Epub ahead of print].
7. Hendren NS, Drazner H, Bozkurt B, Cooper LT Jr. Description and proposed management of the acute COVID-19 cardiovascular syndrome. Circulation 2020;141:1903-14.
8. Bavishi C, Maddox TM, Messerli FH. Coronavirus Disease 2019 (COVID-19) infection and renin angiotensin system blockers. JAMA Cardiol 2020;Apr 3 [Epub ahead of print].
9. AlGhatrif M, Cingolani O, Lakatta EG. The dilemma of coronavirus disease 2019, aging, and cardiovascular disease: insights from cardiovascular aging science. JAMA Cardiol 2020;Apr 3 [Epub ahead of print].
10. Krumholz HM. Where Have All the Heart Attacks Gone? (New York Times website). Available at: https://www.nytimes.com/2020/04/06/well/live/coronavirus-doctors-hospitals-emergency-care-heart-attack-stroke.html Accessed 05/01/2020.
11. Garcia S, Albaghadi MS, Merag PM, et al. Reduction in ST-segment elevation cardiac catheterization laboratory activations in the United States during COVID-19 Pandemic. J Am Coll Cardiol 202075: 2871-2.
12. Poppas A, Rumsfeld JS, Wessler JD. Telehealth is having a moment. Will it last? J Am Coll Cardiol 2020;May 28 [Epub ahead of print].
13. Medicare Telemedicine Health Care Provider Fact Sheet (Centers for Medicare & Medicaid Services website). 2020. Accessed at: https://www.cms.gov/newsroom/fact-sheets/medicare-telemedicine-health-care-provider-fact-sheet. Accessed 04/10/2020..
14. Reinventing cardiovascular care in two weeks: an industry adapts to a pandemic (MedAxiom website). Available at: https://www.medaxiom.com/resource-center/clinical-strategy-and-care-delivery/re-inventing-cardiovascular-care-in-two-weeks-an-industry-adapts-to-a-pandemic/. Accessed 06/21/2020.
15. Sandesara PB, Lambert CT, Gordon NF, et al. Cardiac rehabilitation and risk reduction: time to "rebrand and reinvigorate". J Am Coll Cardiol 2015:65:389-95.
16. Carter BL, Rogers M, Daly J, Zheng S, James PA. The potency of team-based care interventions for hypertension: a meta-analysis. Arch Intern Med 2009;169:1748-55.
17. Richardson S, Shaffer JA, Falzon L, Krupka D, Davidson KW, Edmondson D. Meta-analysis of perceived stress and its association with incident coronary heart disease. Am J Cardiol 2012;110:1711-6.
18. Karekla M, Panayiotou G, Collins BN. Predictors of urge to smoke under stressful conditions: an experimental investigation utilizing the PASAT-C task to induce negative affect in smokers. Psychol Addict Behav 2017;31:735-43.
19. Yau YHC, Potenza MN. Stress and eating behaviors. Minerva Endocrinol 2013;38:255-67.

Clinical Topics: Cardiovascular Care Team, COVID-19 Hub, Diabetes and Cardiometabolic Disease, Dyslipidemia, Heart Failure and Cardiomyopathies, Acute Heart Failure

Keywords: Dyslipidemias, COVID-19, Pandemics, Coronavirus, severe acute respiratory syndrome coronavirus 2, Peptidyl-Dipeptidase A, Cardiac Rehabilitation, Medication Adherence, Outpatients, Tobacco, Blood Pressure, Depression, Angiotensin-Converting Enzyme Inhibitors, Shock, Cardiogenic, Patient Participation, Pharmacies

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