Surfing the Waves of the COVID-19 Pandemic As A Cardiovascular Clinician.

HomeCirculationVol. 142, No. 2Surfing the Waves of the COVID-19 Pandemic as a Cardiovascular Clinician Free AccessArticle CommentaryPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessArticle CommentaryPDF/EPUBSurfing the Waves of the COVID-19 Pandemic as a Cardiovascular Clinician Payal Kohli and Salim S. Virani Payal KohliPayal Kohli Payal Kohli, Cherry Creek Heart, 250 Fillmore Street, Suite 150, Denver, CO 80206. Email E-mail Address: [email protected] https://orcid.org/0000-0002-1049-5233 Cherry Creek Heart, NBC/9News Medical Expert, Denver, CO (P.K.). Presbyterian St. Luke’s Medical Center, Denver, CO (P.K.). Search for more papers by this author and Salim S. ViraniSalim S. Virani Section of Cardiovascular Research, Department of Medicine, Baylor College of Medicine, Houston, TX (S.S.V.). Section of Cardiology, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX (S.S.V.). Search for more papers by this author Originally published5 May 2020https://doi.org/10.1161/CIRCULATIONAHA.120.047901Circulation. 2020;142:98–100Other version(s) of this articleYou are viewing the most recent version of this article. Previous versions: May 5, 2020: Ahead of Print The way we practice medicine during the coronavirus disease 2019 (COVID-19) pandemic is unprecedented. The healing power of the face-to-face visit and the human touch are no longer privileges afforded to us. Clinical decisions previously made on the basis of appropriate diagnostic testing and careful contemplation are now made on the basis of intuition because of a lack of testing resources. Therapies administered on the basis of data from rigorously conducted clinical trials have been replaced with therapies that are based on anecdotal evidence.The novel coronavirus has, in a few months, collapsed the global economy, changed the landscape of healthcare delivery, and left many types of casualties—human and nonhuman—in its wake. Our only defense is to flatten the curve of destruction by practicing social distancing. It is a paradox that as we flatten the curve of infection, we may inadvertently steepen the curve of non–guideline-based healthcare delivery.The Many Curves of Destruction of COVID-19Experts have described the wave of immediate morbidity that results from direct infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). We are trying to flatten this curve, but it is one of many curves through which the virus wreaks havoc (Figure).Download figureDownload PowerPointFigure. Total health effect of the COVID-19 pandemic. Adapted with permission from Victor Tseng, MD. COVID-19 indicates coronavirus disease 2019; and LTAC, long-term acute care.In addition to patients being affected directly by the virus, a second wave of morbidity will arrive in the coming weeks to months, created by those with conditions not related to COVID-19 who may have needed urgent care but either deferred it or did not receive it. In Lombardy, Italy, ST-segment–elevation myocardial infarction cases were reduced by 70%; in the United Kingdom and in multiple cities across the United States, similar drops in numbers of acute coronary syndrome cases were reported.1 The Spanish Society of Cardiology reported a 57% decrease in diagnostic procedures, a 48% decrease in percutaneous coronary interventions, and a 40% decrease in percutaneous coronary interventions for ST-segment–elevation myocardial infarction, with an increase in use of pharmacologic thrombolysis.2Because of limited resources, category 2 patients (defined as those who have life-threatening illness but their heart and lungs have not stopped working) in the United Kingdom waited an average of 1 hour after calling for emergency services, almost 3 times the usual response time.3 There have also been anecdotal case reports of missed or delayed diagnoses from other chronic conditions attributable to the heightened diagnostic bias on diagnoses related to COVID-19. The effect of patients limiting hospital visits because they fear contracting COVID-19, lengthy delays in patient care from delays in acute services (which prolong door-to-balloon time), lack of adequate interventional cardiology physician staffing, and necessary changes that may promote suboptimal treatment options (ie, thrombolysis over percutaneous coronary intervention) will result in significantly higher burden of cardiovascular disease complications in the coming months to years. This is especially relevant with respect to time-sensitive conditions such as acute coronary syndromes, where acute management dictates long-term prognosis.The third wave is an aggregate representation of the multiple future waves of COVID-19 infection, which are likely to continue to occur as stay-at-home orders are relaxed, until a vaccine is available or until enough infection has occurred to generate herd immunity.The fourth wave, which can also be termed the prevention curve, is likely to start peaking 1 or more years from now, because of interruption of care pathways that focus on primary and secondary prevention for chronic conditions, such as hypertension, diabetes mellitus, congestive heart failure, atherosclerotic cardiovascular disease, and atrial fibrillation.The fifth wave, which has begun and will continue rising for the next several years, depicts the mental health and economic fallout of this epidemic, which directly and indirectly influences the peak of the other curves.We must ask ourselves how to flatten the curve of the immediate effect of the pandemic while flattening all the other curves, because our current approach may be paradoxically steepening those other curves.Healthcare During A PandemicAs the time course of COVID-19 and its effects continues to drag on without a clear end point, educating patients about seeking treatment for urgent and routine complaints even during a pandemic and preventive healthcare will have to resurface as important goals. Social distancing is likely to continue even after many stay-at-home orders are lifted until a vaccine is available; thus, delaying nonurgent visits indefinitely is no longer a viable option. We must find creative ways to innovate and reengage both clinicians and patients with respect to their cardiovascular health.There have been some silver linings from this pandemic. First, it has put health and specifically preventive health at the forefront of patients’ minds. Patients have become more empowered with respect to awareness of effects of disease and the importance of disease prevention. Another silver lining has been the acceleration of innovation resulting in brisk implementation of healthcare delivery models of telemedicine, remote visits, and virtual care that would otherwise have taken many years to incorporate into our workflow and have improved access to care.4 Yet another silver lining has been the willingness of payers to provide zero-cost virtual visits to patients and provide reimbursements to clinicians for such visits. In a short time, the United States has seen a 10-fold increase in virtual visits and countries such as Scotland have reported a 1000% increase in use of videoconferencing.5We see this as a once-in-a-lifetime opportunity to use technology to redefine cardiovascular disease care as a continuous year-long process, rather than a dichotomous once-or-twice-a-year in-person visit. Screening and medication titration as well as healthcare maintenance, which had largely been done during in-person visits, can be done as remote visits and secure messaging. Virtual visits are not meant to deemphasize the importance of the in-person visit and its dedicated place in establishing and propagating a therapeutic relationship but rather serve as an important adjunctive tool that can be capitalized on during crisis times to continue to uphold the pillar of guideline-based healthcare delivery. We must not let guideline-based care become another casualty of this deadly epidemic.DisclosuresDr Kohli has served on the speakers' bureau for Boston Scientific, Amarin, and Esperion; has served on the advisory board for Boston Scientific, Esperion, Doximity (no financial renumeration), and Oliver Wyman; has received honoraria from the ACC/ABIM Question Writing Committee, CryoLife, and Amgen, and as a Current Atherosclerosis Reports Section Editor; has served as a consultant for Grand Rounds; and served as a writer for Healthline and advisor for DocWire/MashUP MD. Dr Virani has received grant support from the Department of Veterans Affairs, the World Heart Federation, and the Tahir and Jooma family; has received honorarium from the American College of Cardiology (Associate Editor for Innovations); and has served as a Steering Committee member for the Patient and Provider Assessment of Lipid Management (PALM) registry (no financial remuneration).FootnotesThe opinions expressed in this article are not necessarily those of the editors or of the American Heart Association.https://www.ahajournals.org/journal/circPayal Kohli, Cherry Creek Heart, 250 Fillmore Street, Suite 150, Denver, CO 80206. Email payal.kohli@post.harvard.eduReferences1. Wood S. The Mystery of the Missing STEMIs During the COVID-19 Pandemic.https://www.tctmd.com/news/mystery-missing-stemis-during-covid-19-pandemic. Published April 2,2020. Accessed April 12, 2020.Google Scholar2. Rodríguez-Leo O, Alvarez-Cid B, Ojeda S, Martin-Moreiras J, Rumoroso JR, Serrador A, Cequier A, Romaguera R, Cruz I, Perez de Prado A, et al. Impact of the COVID-19 pandemic on care activity in interventional cardiology in Spain.REC Interventional Cardiology. 2020; 2:96–105. doi: 10.24875/RECIC.M20000120Google Scholar3. Blanchard S. London Ambulances Took an Hour on Average to Reach Heart Attack Patients in the Capital in March Amid Capital’s Spiralling Coronavirus Crisis.https://www.dailymail.co.uk/news/article-8203897/London-ambulances-took-HOUR-average-reach-heart-attack-patients-March.html. Published April 9,2020. Accessed April 12, 2020.Google Scholar4. Mehrotra A, Ray K, Brockmeyer DM, Barnett ML, Bender JA. Rapidly converting to “virtual practices”: outpatient care in the era of COVID-19 [published online April 1, 2020].NEJM Catalyst. doi: 10.1056/CAT.20.0091. https://catalyst.nejm.org/doi/full/10.1056/CAT.20.0091Google Scholar5. Webster P. Virtual health care in the era of COVID-19.Lancet. 2020; 395:1180–1181. doi: 10.1016/S0140-6736(20)30818-7CrossrefMedlineGoogle Scholar eLetters(0)eLetters should relate to an article recently published in the journal and are not a forum for providing unpublished data. Comments are reviewed for appropriate use of tone and language. Comments are not peer-reviewed. Acceptable comments are posted to the journal website only. Comments are not published in an issue and are not indexed in PubMed. Comments should be no longer than 500 words and will only be posted online. References are limited to 10. Authors of the article cited in the comment will be invited to reply, as appropriate.Comments and feedback on AHA/ASA Scientific Statements and Guidelines should be directed to the AHA/ASA Manuscript Oversight Committee via its Correspondence page.Sign In to Submit a Response to This Article Previous Back to top Next FiguresReferencesRelatedDetailsCited By Han L, Zhao S, Li S, Gu S, Deng X, Yang L and Ran J (2023) Excess cardiovascular mortality across multiple COVID-19 waves in the United States from March 2020 to March 2022, Nature Cardiovascular Research, 10.1038/s44161-023-00220-2, 2:3, (322-333) Meador M, Coronado F, Roy D, Bay R, Lewis J, Chen J, Cheung R, Utman C and Hannan J (2022) Impact of COVID-19-related care disruptions on blood pressure management and control in community health centers, BMC Public Health, 10.1186/s12889-022-14763-9, 22:1 Cassell K, Zipfel C, Bansal S and Weinberger D (2022) Trends in non-COVID-19 hospitalizations prior to and during the COVID-19 pandemic period, United States, 2017–2021, Nature Communications, 10.1038/s41467-022-33686-y, 13:1 Virani S (2022) Statins and Primary Atherosclerotic Cardiovascular Disease Prevention—What We Know, Where We Need to Go, and Why Are We Not There Already?, JAMA Network Open, 10.1001/jamanetworkopen.2022.28538, 5:8, (e2228538) Gordon Patti K and Kohli P (2022) COVID’s Impact on Non-communicable Diseases: What We Do Not Know May Hurt Us, Current Cardiology Reports, 10.1007/s11886-022-01704-6, 24:7, (829-837), Online publication date: 1-Jul-2022. 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Batista S, Souza A, Nogueira J, Andrade F, Thumé E, Teixeira D, Lima-Costa M, Facchini L and Nunes B (2020) Comportamentos de proteção contra COVID-19 entre adultos e idosos brasileiros que vivem com multimorbidade: iniciativa ELSI-COVID-19, Cadernos de Saúde Pública, 10.1590/0102-311x00196120, 36:suppl 3 July 14, 2020Vol 142, Issue 2 Advertisement Article InformationMetrics © 2020 American Heart Association, Inc.https://doi.org/10.1161/CIRCULATIONAHA.120.047901PMID: 32369419 Originally publishedMay 5, 2020 KeywordsCOVID-19patient carepandemicsPDF download Advertisement SubjectsEpidemiologyPrimary PreventionSecondary Prevention