The Impact of COVID-19 on Pulmonary Hypertension
- In a US survey of 77 Comprehensive Care Centers for pulmonary hypertension (PH), the incidence of coronavirus disease 2019 (COVID-19) infection in patients with pulmonary arterial hypertension (PAH) was 2.1 cases per 1,000 patients, which is similar to the general US population. The associated mortality was 12%.
- PH programs should adopt a visit schedule to balance exposure risk with benefit of evaluation. Telemedicine visits are valuable alternatives to in-person visits as long as patient accessibility is addressed.
- A thorough evaluation of PH requires extensive testing, both at initial evaluation and during follow-up visits. The pandemic required programs to establish protocols for PAH work-up to decrease the risk of exposure to or transmission of COVID-19.
COVID-19 has had a significant impact on all aspects of PH, from diagnosis and management to observing an increased risk of death in patients with PAH. In addition, because of the vulnerable nature of this population, the pandemic has impacted the very manner in which care is delivered in PH. Although the result of a time of enormous strife and hardship, many of the changes observed in PH care are arguably positive and reflect necessary changes that should have happened long ago. Other changes are more reactionary and reflect the significant challenges faced by health care providers and patients during this harrowing time.
The risks associated with COVID-19 in patients with PH are significant. In a US survey of 77 PAH Comprehensive Care Centers, the incidence of COVID-19 infection was 2.1 cases per 1,000 patients with PAH, which is similar to the incidence of COVID-19 infection in the general US population. But although COVID-19 did not seem to be more prevalent in patients with PAH, the mortality did appear to be higher at 12%. In addition, 33% of patients with PAH who were infected with COVID-19 ended up being hospitalized.
With the outbreak of COVID-19, it became necessary to revisit the manner in which patients receive care to decrease risk of contracting the virus. Schedules were adopted to balance exposure risk with benefit of evaluation. Prior to the COVID-19 pandemic, <10 % of PAH centers in the United States provided telemedicine as an option for clinical visit. Today, 97% of PAH centers offer routine video-enabled visits. Unfortunately, challenges have persisted regarding patient accessibility during this time. For many patients with low socioeconomic status or who live in remote areas, access to internet and video-enabled cameras or phones is limited, thereby potentially creating further obstacles to accessing care.
A thorough evaluation of PH requires extensive testing, both at initial evaluation and during follow-up visits. The pandemic required programs to establish protocols for PAH work-up to decrease the risk of exposure to or transmission of COVID-19. For example, since March 2020, 60% of PH programs in the United States have decreased the number of echocardiograms performed by 60-99%. Similarly, there has been a decrease in testing stable patients with pulmonary function tests or 6-minute walk distances. Because of the inherent respiratory risks and cleaning necessary for ventilation-perfusion scans, most programs have shifted to perfusion-only imaging or spiral computed tomographic pulmonary angiography to evaluate for chronic thromboembolic PH. If a perfusion scan is truly normal, then chronic thromboembolic PH has been adequately ruled out and there is no need for the ventilation component of the scan. This is one of the protocol changes introduced because of COVID-19 that was likely overdue and should be continued beyond the pandemic.
Not all patients with PH require right heart catheterization (RHC). RHC is most useful in times when clinical uncertainty exists as to the cause of PH or if PAH-specific symptoms are being considered. To this end, PH centers stratified patients regarding the need for RHC based on pre-test probability of Group 1 PAH and the risk profile of new or returning patients who require augmentation of PAH therapy. For stable patients with high likelihood of having Group 2 and 3 PH, it is worth considering whether elective new patient evaluations, and RHC, can be deferred due to the lack of established therapies for these disease states currently.
The impact of COVID-19 on health care delivery and on society at large is going to be felt for years to come. Within the field of PH, there has been a seismic shift in care delivery, and practice patterns have changed with new standards that likely should have been introduced years ago.
- Ryan JJ, Melendres-Groves L, Zamanian RT, et al. Care of patients with pulmonary arterial hypertension during the coronavirus (COVID-19) pandemic. Pulm Circ 2020;10:2045894020920153.
- Lee JD, Burger CD, Delossantos GB, et al. A Survey-based Estimate of COVID-19 Incidence and Outcomes among Patients with PAH or CTEPH and Impact on the Process of Care. Ann Am Thorac Soc 2020;Jul 29:[Epub ahead of print].
- Zamanian RT, Pollack CV Jr, Gentile MA, et al. Outpatient Inhaled Nitric Oxide in a Patient with Vasoreactive Idiopathic Pulmonary Arterial Hypertension and COVID-19 Infection. Am J Respir Crit Care Med 2020;202:130-2.
Keywords: Hypertension, Pulmonary, COVID-19, Pandemics, severe acute respiratory syndrome coronavirus 2, Coronavirus, Uncertainty, Follow-Up Studies, Prevalence, Telemedicine, Echocardiography, Health Personnel, Cardiac Catheterization
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