Long COVID and heart disease
The SARS-CoV-2, the cause of the novel coronavirus pandemic, has significantly impacted cardiovascular health care.
From the beginning of the pandemic in early 2020, there were early indications of a dubious connection between COVID-19 and heart disease. There were early indications that patients with hypertension, heart disease, and diabetes had higher rates of complications and death. This finding was noted in all countries and in major research publications, leading to recommendations for more rigorous prevention measures for heart disease patients. Cardiologists at the Heart Institute of the Caribbean (HIC) were among the first group of experts to bring this problem to global attention. In a landmark publication in a leading cardiology journal, Clinical Cardiology, in June 2020, HIC investigators reported that patients with pre-existing cardiovascular comorbidities demonstrated an increased risk of infection with SARS-CoV-2 and seemed to have worse clinical outcomes. This report highlighted data from several investigators showing high complication rates in COVID-19 patients with cardiovascular disease, diabetes, and hypertension, with a mortality rate of 10.5 per cent reported in cardiac patients and 7.3 per cent and 6.0 per cent for diabetes and hypertension patients, respectively. As early as May 2020, HIC was among the first to institute strict protocols to improve access to patients with heart diseases in a COVID-free health-care environment. After more than two years of the pandemic, about 500 million people have been infected with the SARS-CoV-2 virus, with over six million dead. In Jamaica, about 130,000 infections have been reported, with nearly 3,000 dead. We believe the number of infected, and dead are significantly more as many cases are likely under reported.
Tsunami of heart diseases post-COVID
While the world is still reeling from the health care and socio-economic impact of the pandemic, troubling signals of a new tsunami of heart and cardiovascular diseases are becoming apparent. There is now strong evidence that survivors of COVID-19 are at significantly increased risk of heart and cardiovascular diseases, especially in the first several months following recovery. It is, therefore, advisable that they see a doctor as soon as possible if they develop worrisome symptoms that suggest cardiac involvement. COVID survivors should watch out for symptoms like chest pain, fainting, palpitations, shortness of breath at rest or with exertion, unusual fatigue, or decreased activity tolerance. These may be markers of long-term complications of COVID-induced cardiovascular disease. In a major Swedish study published August 14, 2021, in The Lancet, a high-impact medical journal, researchers found strong evidence that heart attack and stroke risk rise sharply in the weeks following a COVID-19 diagnosis. In that study which included every person in Sweden diagnosed with COVID-19 from February 1, 2020, to September 14, 2020, numbering nearly 87,000 people, it was shown that in the week after a COVID-19 diagnosis, the risk of a first heart attack increased by three to eight folds when compared to 348,000 Swedish people of similar age and sex who did not have the virus. The risk of a first stroke caused by a blood clot multiplied by three to six times. This pattern has been described for other viral infections like influenza, but COVID-19 infections appear to have a more profound and exaggerated increase in long-term cardiovascular complications, perhaps because they trigger an exaggerated inflammatory response that makes blood clots more likely. The primary cardiac presentations in long-COVID include recurrent palpitations, arrhythmias, inappropriate tachycardia, and fainting episodes. In a smaller subset of patients, we note lingering pericarditis or myocarditis. Depending on what study you read, a percentage of patients with acute COVID-19 infection will develop long-lasting sequelae. While the number of such patients is uncertain, there is evidence that more than 50 per cent of older patients with significant comorbidities will experience some form of long-COVID. Most studies show a range of 30-35 per cent overall. More than half of these patients will experience predominantly heart-related symptoms, including shortness of breath, exertional intolerance, chest pain, heart palpitations, sensations of light-headedness, dizziness, and sometimes frank fainting episodes.
This could mean that nearly 50,000 of the reported cases of COVID-19 so far in Jamaica are at risk of developing long COVID-19 complaints, with more than 25,000 of those patients presenting with cardiovascular complaints. The actual numbers are likely to be significantly more than reported. Many Clinicians now believe that long-COVID is very similar to the autonomic dysfunction caused by postural orthostatic tachycardia syndrome (POTS). POTS is a challenging disease that many clinicians are not versed in and therefore not comfortable treating. From a cardiac standpoint, about 20-40 percent of patients with long COVID-19 may have features reminiscent of POTS, or inappropriate tachycardia.
Long COVID clinic at HIC
The HIC has had a robust Autonomic Function Lab for nearly 20 years and has successfully treated many Jamaican patients with autonomic dysfunction. The Autonomic Function Lab at HIC is the only such facility in Jamaica. In recognition of the current need, HIC will be opening a Long Covid Clinic effective May 1, 2022, to cater to COVID survivors with long COVID cardiovascular symptoms. Many of these patients would need to be studied with standard Head Upright Tilt Table (HUTT) studies and other cardiac diagnostic techniques to reveal abnormalities in heart rate response and initiate appropriate treatment for autonomic dysfunction. The long COVID clinic at HIC will be open to all Jamaican survivors of COVID-19 who continue to have heart related symptoms including chest pain, palpitations or irregular heartbeats, shortness of breath, dizziness, or fainting. With proper evaluation and treatment, many patients with long COVID can find relief.
Dr Ernest Madu, MD, FACC and Dr Paul Edwards, MD, FACC are consultant cardiologists for Heart Institute of the Caribbean (HIC) and HIC Heart Hospital. HIC is the regional centre of excellence for cardiovascular care in the English-speaking Caribbean and has pioneered a transformation in the way cardiovascular care is delivered in the region. HIC Heart Hospital is registered by the Ministry of Health and Wellness and is the only heart hospital in Jamaica. Correspondence to info@caribbeanheart.com or call 876-906-2107