Coronavirus in Context: The Relationship Between COVID-19 and Your Heart

[MUSIC PLAYING] Welcome to Coronavirus in Context. I'm Dr. John Whyte, Chief Medical Officer at WebMD. We know about the relationship between COVID-19 and the lungs, but what about the relationship between coronavirus and the heart, and why are so many people of color dying at a greater rate than Caucasians? To discuss this and many other questions is my guest, Dr. Clyde Yancy. He is Professor of Medicine and Chief of Cardiology at Northwestern. Dr. Yancy, thanks for joining me.

John, thank you for inviting me. These are important concepts, and I'm looking forward to our conversation.

Now, we all know that people with heart disease are at increased risk of COVID-19, but let's talk about perhaps some emerging science. Is COVID-19 directly affecting the heart?

So John, this is really a great place for us to start. For all of your viewers, let's remember that COVID-19 is a lung condition. It's a respiratory disease. But there are two important dimensions of that respiratory disease. One, those persons who get the most severe complications have underlying cardiovascular disease, and two, unfortunately, sometimes the last challenge for those patients is a cardiovascular challenge. So having this conversation with Dr. Whyte today is really important to understand what's that intersection between COVID-19 and heart disease.

So what is it?

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So it's really an important conversation, because first it starts with why do certain people appear to have poor outcomes? Well, the combination of high blood pressure or diabetes, along with pre-existing heart disease, like coronary disease or previous heart failure, and particularly when there's evidence of myocardial injury -- and John, you know we can measure that in the bloodstream -- those are the scenarios where patients, unfortunately, need breathing support. They need ventilators. We've heard so much about that. And they go on to suffer even greater consequences, like more heart failure. We really worry about those patients.

Now John, the bigger question is, so why? What is it about heart disease that puts people at risk? Right now, we think there are probably three theories. And let me emphasize theories.

OK.

One could be direct involvement from COVID-19 in the heart. That is, does it cause an inflammatory condition in the heart per se, something that, John, you and I would call myocarditis. There's some case reports, but that doesn't appear to be the predominant problem.

Would that be for persons who may not have any underlying heart disease?

That may be one reason why people who don't have underlying heart disease, particularly those that are younger, are really struggling with this condition. And those are the most tragic scenarios, the 35-year-old father or the 41-year-old mother who comes in and has a tragic outcome. The second thing we worry about is whether or not what we've observed, that is about 1 in 3 patients with COVID-19 have a tendency towards blood clots. Are those blood clots affecting cardiovascular function? We don't know yet if that's true, but we do know the phenomenon is occurring.

But John, the most likely reason right now is something that you and I understand well as physicians. It's supply/demand. If you have a heart that is limited but the demand is excessive, that exceeds the capability of that heart to function, then we will see cardiac problems. So right now, we're working with about three different explanations, but we know the risk is real.

Yeah. There was an article in the Journal of American College of Cardiology that said 1 out of 5 patients in Wuhan, China had heart damage. Um, they put everyone in one pile, so those folks that had heart disease, but some folks did not, yet we saw heart damage. And we keep talking about the lungs. Many people are. So are we missing something there in terms that it has an impact on the heart? You know, perhaps in terms of, you know, clots, and we need to think a different treatment paradigm?

So John, I'm glad you brought that up because there is information that now is replicating this observation from Asia, from Europe, and even beginning to emerge in the United States. Here is the factor that links all of those observations. When there's evidence of heart injury, absent pre-existing disease or in the setting of pre-existing disease, when there's evidence of heart injury, patients don't fare very well. But particularly if there's evidence of heart injury in a setting a pre-existing disease, we know that's the group in whom we have the greatest concern because they suffer the greatest consequences.

So the way that's changed behavior, we begin to immediately surveil evidence of heart injury as soon as a COVID-19 patient is admitted, and especially if that patient fits what you and I know, John, as a phenotype, but a characteristic profile of being older and having pre-existing hypertension, diabetes, obesity or heart disease. We start checking enzymes and laboratory tests right away, because we know what it means if they go in a contrary direction.

And coronavirus would not be the first virus that caused heart damage. We see that in other viruses. Not common, but it happens.

So that really is a very insightful question, John, because we have seen it and reported this in a setting of influenza, we've seen it and reported it in the setting of the previous SARS viruses. And with the initial outbreak of HIV/AIDS, we definitely saw it then again. So it is not unprecedented for viruses, particularly these very pathogenic viruses. You and I know that -- know that to make a very bad virus.

That's true.

We know

that the heart can be a target.

Dr. Yancy, I want to ask you about two competing reports. We've been hearing about cases in New York, an increased number of heart attacks, uh, that are coming in through 9-1-1, yet in other areas of the country, it seems like there is a dip in the number of people that are presenting with chest pain. Yet, you and I know it still must be going on. So what's happening? In some areas of the country, there's more cases. Um, in other areas of the countries, not so much. How do we reconcile that?

So John, I'm glad you brought this up, because this is something that's causing a lot of us -- a lot of leaders in medicine are trying to think about this. We obviously need data because we're just basing this on empiric observations. And as you say, it can be one way or another depending on the circumstances. But here are some considerations. One, people could be staying home out of fear of presenting to the emergency department. Does that mean there will be a wave of heart failure weeks and months from now because people stayed away?

Two, there could well be -- and believe it or not, this is possible -- a reduction in these episodes, because guess what? With so many people at stay at home directions, they're not exerting themselves, they're not putting themselves up physically, and they may be remaining below a level of effort that might precipitate these events. It's a theory, but there's no proof yet.

But here's the thing that's most provocative. Almost every major center has stood up a telehealth platform almost overnight. I wonder what's happening with patients who have immediate access to providers almost on demand, can have conversations, can anticipate problems, can have a restructuring of their home regimens, their lifestyle directions. We might learn something off target.

We did telehealth to protect patients from coming to clinics and congregating, but it could be that there is a benefit there just by virtue of access and having their undivided attention. You know when a patient comes to my office, between parking and lunch and getting in the room on time, getting out of the room, who has the effort to pay attention to what happens during the physician/patient engagement? With the patient in the comfort of their home, having a conversation that's about them that's from their physician or care provider could be a benefit there that we hadn't expected.

But even in this setting of COVID-19, what do those patients with chest pain do? Are they still calling 9-1-1? Do they still go to the ER?

That's what we don't know. My concern is that they are not calling 9-1-1 out of fear and are not self-presenting to emergency department out of fear, and are either experiencing this natural history quietly or, worse, succumbing to this natural history. And it's going to take a lot of data analytics to finally answer that question. So I think the --

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Should we be telling them to come in?

Oh, we are telling them to come in. In my own institution, we have sent out directives after directives, please, do not be hesitant. We are still a hospital.

Yeah.

We're still a full services hospital. Our cath labs are still open. We take care of patients.

Yeah.

I spend half my day on the phone with patients, reassuring them, taking care of them via the phone. And I've already directed several patients to go to emergency departments because they've had conditions that needed help.

Now you mentioned provocative a little earlier. So I'm going to ask you a provocative question, if I may, Dr. Yancy.

Of course.

You're in Chicago. You know these numbers. People of color are dying at six times the rate of cor -- from coronavirus than Caucasians. What's going on, and how do we address that?

So the numbers are sobering. And as you can imagine, this impacts me personally deeply. The infection rate is three times higher in black counties in this country compared to white counties, and the death rate is six times higher in black counties compared to white counties. There's nothing about race per se that makes anyone more likely to become infected or any more likely to die, but there's everything about life and living circumstances that explains at least some of this.

Let me be more clear. If you live in a community that is at risk, defined by the SES status, by housing density, by crime rates, by poverty, you will have a very difficult time practicing social distancing. You will have a difficult time finding hand sanitizers. You may have reluctance to wear a mask for obvious social reasons. You end up contracting the virus more frequently.

Think about what happens when you contract the virus. Think about what we've just talked about. If you have concomitant hypertension, obesity and heart disease, you have more complications. And guess which population has the highest burden of hypertension, has the highest burden of heart disease, highest burden of obesity?

We put all this information together and say, this is another example of a very compelling, painful example of the health care disparities in this country that we've known to exist for several decades. Maybe this is the bellwether event when we realize that we can't, as a civil society, sit back and let a six-fold higher death rate affect just one group of the population. It really is food for thought.

But Dr. Yancy, you know, pre-COVID-19, we had these significant disparities. This really isn't surprising to anyone, you know, who studies, um, how we deliver care. What do you think are one or two ways that this epidemic is perhaps changing, uh, the way we deliver health care, and the way we think of health?

Well, a couple of things are very important in your question. I think that, prior to COVID-19, we had become very accustomed to recognizing, identifying, profiling these differences in health outcomes, and attributing those differences to disparities. But this is the first time we've seen something as shocking as a 600% higher likelihood of the most dreadful outcome. That really is, whether you call it the wakeup call or the tipping point or any other such inciting language, that really is a moment of pause. We have to think very carefully now, how does that impact the entirety of our society? Not just one group.

What about the workforce? What about the economic contributions? What about the demands that an ill population has on our health care environment? This is not a them problem. This is an everybody problem now. And recognizing this, this may finally be the opportunity to pull the Band-Aid of health care disparities, and not treat it with a Band-Aid anymore, but be more definitive. It will be very interesting to see what we learn from this and what we do differently going forward.

What do we tell our viewers that are watching? For those that have heart disease, those that are concerned about chest pain, for those from minority populations, what words of advice can you give these viewers?

I want to be -- speak very plainly with your viewers. We are facing a crisis, a crisis like none we've ever seen, at least in my lifetime, maybe in your lifetime. But we don't have to succumb to this crisis. The directions are clear. We know what works. Social distancing, physical isolation, particularly for those already with cardiovascular disease. But let's not practice social isolation. Don't leave people on their own. Don't forget to engage. And use virtual platforms to do that.

Secondly, we know that testing is very helpful. If, by any chance, there's any symptom, every hospital in the country has a hotline, has an algorithm, has a way for you to acquire testing and get that information, and not be someone who transmits the disease to another person. We also understand that, as hard as it's been, so many hospitals, if not every hospital, has created every opportunity possible to provide care. Don't delay in presentation. Don't delay in presentation for your other ailments. Don't let that be another consequence of this.

So be aware, yes, it is frightening, but it is manageable. So we are in a crisis, but it is not inevitability. Social distancing works. Hand hygiene works, clearing the surfaces, a mask in public. Be very careful with older people, those with heart disease. Keep them at a distance physically, but not emotionally. And realize that the health care systems in this country are heroic institutions. They have stepped up, and there are champions after champions after champions. And we're here to serve. We're here to help, and we're here to make a difference in your life.

Well those are good words of advice. I want to thank you, Dr. Yancy.

Thank you very much, John. I really appreciate the opportunity to talk to you about this.

And I want to thank you for watching Coronavirus in Context. I'm Dr. John Whyte.