• Scientists have long known that viral infections, including the flu and now COVID-19, can trigger heart events and stroke.
  • The type of heart disease and it's treatment may play a role in the risk of severe COVID-19, but the exact link remains unclear.
  • People who take ACE inhibitors and ARBs for blood pressure should remain on them unless their doctor says otherwise because it's too early to say if the medicines increase the risk of coronavirus infection.
  • People with preexisting heart disease should shelter in place and avoid sick people.

Video Transcript

JOHN WHYTE: Hello, I'm Dr. John Whyte, Chief Medical Officer at WebMD, and welcome to Coronavirus In Context. Today we're going to talk about the role of heart disease in coronavirus. My guest is Dr. Mitchell Elkind who's Professor of Neurology at Columbia University College of Physicians and Surgeons and the President-elect of the American Heart Association. Thanks for joining me today.

MITCHELL ELKIND: Thank you so much for having me.

JOHN WHYTE: Let's start off with the American Heart Association recently has published some information about those patients who have heart disease and who may have contracted coronavirus. What do consumers with heart disease need to know?

MITCHELL ELKIND: Well, we've known for some time that various kinds of infections, things like even the flu virus, for example, can trigger cardiac events and even strokes. And now what we have found is that this particular virus, the coronavirus that's causing this pandemic, seems to have some particular tropism or a tendency to affect the heart as well because of the way that it enters cells.

And so, uh, in China they've seen evidence that this virus can damage the heart directly, and this obviously has implications for patients who already have heart disease. And we are seeing already that mortality rates among patients who have preexisting heart disease or high blood pressure or even diabetes are higher than in people who don't have those problems.

JOHN WHYTE: Dr. Elkind, is it all types of heart disease, or is risk different if, perhaps, you have heart failure with an ejection fraction less than 20% versus you recently had a stent placed for some -- for a blockage? Do we know that at all?

MITCHELL ELKIND: Yeah, as far -- it's a great question. And as far as I know, I don't think we have those answers just yet. It's been remarkable how quickly the literature has grown on this in just the three months since the pandemic began. We already have, uh, high-profile papers in great journals with thousands of patients, and -- and yet we don't have that kind of specific information.

Part of the issue could be also not just the kind of conditions people have but the medications that they're taking. So -- so I -- I think that, you know, there's an issue with hypertension. Certainly patients with heart failure who are already hemodynamically compromised are going to be at increased risk as well.

JOHN WHYTE: Is there any belief that perhaps heart disease is making someone immunocompromised? Is there any belief on that, or do you think it's mostly about circulation and blood supply and oxygenation?

MITCHELL ELKIND: I -- I haven't seen anything to suggest that heart disease immunocompromises people, but one way in which this virus works -- actually the way in which it enters cells is by binding to a receptor on cells called the ACE2 receptor, the Angiotensin Converting Enzyme 2 receptor, similar to the ACE receptor itself. And that particular receptor is found in lung tissue, which is why the virus is able to enter lung cells and cause so much damage there. But it's also found in heart tissue. And so there may actually be a direct way in which the virus can then enter heart tissue and cause damage through that mechanism.

JOHN WHYTE: And you've seen the data, uh, from Europe about ACE inhibitors, ARBs, and AJ and others have put out some guidance. What do we tell patients who might be hearing this information on social media, on the news about the role of ACE inhibitors, ARBs, and perhaps NSAIDS as well. Can you provide some guidance for our listeners?

MITCHELL ELKIND: Sure. So it's a very complicated story. I'll start just by saying that -- so one issue with the ACE inhibitors and the ARBs is that they -- uh, although they're great drugs for treating, uh, high blood pressure and heart failure, they also can lead to an increase in ACE2-receptor presence on cell. So there's an upregulation of the ACE2 receptor in response to those medications.

And so theoretically there's some concern that people on those medications may have increased receptors to serve as targets for the virus. That would obviously be bad. But at the same time, there is evidence before this outbreak from -- from other studies that the ACE inhibitors and the ARBs may have some benefits in patients with severe lung disease, perhaps through an anti-inflammatory mechanism or other pathways.

And so it's really a, uh -- you know, a positive and a negative effect that we're seeing. And at this point in time, we can't know which one is, uh -- is better or worse. And so that's why the American Heart Association, the American College of Cardiology, and the Heart Failure Society of America put out this joint -- very rapid joint statement saying that at this point in time, it's too early to say to people, don't take those medications -- too early to say use those medications and treat this. Uh, we just don't have that information, and our feeling is that right now people should continue, uh, those medications that they're on because stopping them, if they're stable with their heart disease or stable with their high blood pressure, stopping those medications suddenly could lead to more adverse --

JOHN WHYTE: Absolutely.

MITCHELL ELKIND: [INAUDIBLE].

JOHN WHYTE: It's all about risk.

MITCHELL ELKIND: Absolutely also more -- more information is needed. So we're going to need more research on this.

JOHN WHYTE: More good information too. Now --

MITCHELL ELKIND: Yes.

JOHN WHYTE: -- you're -- you're a neurologist. What about the relationship between stroke, stroke risk, and coronavirus? What -- what are we learning?

MITCHELL ELKIND: Yeah, so there have actually just been a couple of reports out now that suggests that among patients with coronavirus infection there is an increased risk of stroke and it looks like about a 5% -- 5% of patients have stroke. We don't have a controlled study really, so it is hard to say if it clearly increases the risk or just that these patients are the types of patients who are going to have strokes anyway. But there seems to be a rather high rate of stroke among patients who are seriously ill with this -- with this coronavirus.

JOHN WHYTE: What are you seeing in New York?

MITCHELL ELKIND: Well, as you know, New York is one of the hot spots for this right now. We're -- we're, um, I think, at the front of the wave that's going to, you know, hit the US. Seattle, where I have close colleagues, and -- and here in New York are seeing the brunt of it first.

We are just beginning to see it really start to hit our hospitals. I would say that, uh, we're perhaps still just a little bit in the calm before the storm. We absolutely anticipate it's going to get a lot worse. And, um, uh, we're going to have to see, you know, how we can best respond to it.

I think right now the -- the critical needs for us are, uh, the lack of personal protective equipment in the hospital, the lack of masks, uh, the kinds of equipment that we need to take care of, um, patients as well as protect the safety of health-care workers. So I know those are the things that hospital leaders here in New York City are -- are working quite hard on.

JOHN WHYTE: Is it too late to get the flu vaccine? Many of the symptoms that we're talking about for coronavirus are very similar to influenza. American Heart has been talking about flu vaccine. What can you tell listeners about the importance of the flu vaccine?

MITCHELL ELKIND: Of course getting the flu vaccine is -- is an important thing for patients with cardiovascular disease. In fact, since 2006, the American Heart Association and the American College of Cardiology have had a joint recommendation that patients with cardiovascular disease get an annual flu vaccine. Ideally, that would have been done earlier in the season, in fall or into the winter, which are peak flu season.

Should patients get it now? That's a complicated question. We are really trying to limit movement and spread and interaction of people. So, um, I don't think we have an epidemiologic study that can address that question accurately. But at this point in time when we're in some locations recommending sheltering in place -- and certainly here in New York City we're recommending that people, uh, not be out and about unless they need to -- it would be, uh, a tough time, I think, to go out, get a flu vaccine, and at the same time expose oneself --

JOHN WHYTE: Right.

MITCHELL ELKIND: -- to -- to coronavirus.

JOHN WHYTE: Now we've been talking a lot about elective procedures. Certainly if someone has chest pain they should still call 911, right? Is a stent placement considered elective procedure? Are people still going to be able to get a stent if they're having chest pain and have blockages?

MITCHELL ELKIND: I think that at this point in time, all necessary urgent or emergent medical procedures will still be undertaken. So of course stenting is done for different reasons. In the setting of acute coronary syndrome, I think that that would remain indicated. Uh, elective procedures, if people are still doing stenting for, uh, chronic angina and that sort of thing, I think would -- would probably be deferred for now.

One of the major reasons for deferring, uh, procedures now is actually the conservation of personal protective equipment. So the kinds of gowns and gloves and masks that are worn during, uh, procedures are going to be at, you know -- are needed tremendously by those caring for coronavirus patients and even more so in the future. So we're really trying to limit all but the most needed procedures.

JOHN WHYTE: Sorry.

MITCHELL ELKIND: That -- that being said, strokes, heart attacks, uh, you know serious --

JOHN WHYTE: They're still going to occur. They -- they still --

MITCHELL ELKIND: They're still going to occur.

JOHN WHYTE: Yeah.

MITCHELL ELKIND: And so we need to -- we -- we can't stop caring for those kinds of patients as well.

JOHN WHYTE: And what should patients ask their cardiologist or ask their neurologist? We're trying to encourage patients to use telemedicine, to call ahead of time. But if there are a couple of questions or concerns that patients should ask their doctor right now, particularly those with heart disease or risk for stroke, what would those questions be?

MITCHELL ELKIND: So the kinds of questions I'm getting are from people who may feel, um, a little bit under the weather, and there's a lot of anxiety. Should I go to the hospital right now or not? And what we are telling people is that they should stay home unless they're having respiratory big problems. So people have a fever or a cough, um, uh, muscle aches, they should remain at home and monitor their symptoms carefully. And if they begin to develop respiratory problems, then certainly they need to come in and be taken care of.

For patients who have preexisting heart disease, this is even more important to remain at home, to stay away from those who potentially could be at risk, which is increasingly anyone in the population -- to remain at home with their families and, if possible, have others go out and -- and get food for them and bring it home.

But people can still go outside. They can enjoy parks. They can enjoy the -- you know, the nice spring weather that hopefully we're all going to be having. It's important to maintain a social distance, but people don't necessarily have to feel locked inside their home only to maintain that kind of social distance.

JOHN WHYTE: Well, Dr. Elkind, I want to thank you for your time this morning. Certainly we want patients to understand the relationship between coronavirus and cardiovascular disease and stroke, and we appreciate you helping to educate our viewers on -- on what they need to know in what can be very confusing times. For more information, certainly folks can come to our website at WebMD.com and Heart.org, correct?

MITCHELL ELKIND: Absolutely. Thank you very much, John.

JOHN WHYTE: Thank you.