COVID-19 and Your Heart

Podcast Transcript

Announcer: Welcome to Love Your Heart, brought to you by Cleveland Clinic's Sydell & Arnold Miller Family, Heart, Vascular and Thoracic Institute. These podcasts will help you learn more about your heart, thoracic and vascular systems, ways to stay healthy and information about diseases and treatment options. Enjoy.

Dr. Svensson: Good morning. We obviously are facing a very different time and we're going to try and answer some questions for you, particularly around procedures being done at the Cleveland Clinic and we know many of you want to access our care.

So together with me today is Samir Kapadia our chairman of Department of Cardiovascular Medicine and also Marc Gillinov our chairman of Cardiothoracic Surgery and we'll try and answer some of your questions.

As a broad introduction, obviously the new virus, coronavirus that is affecting so many people in the world has come as a big shock to everybody. However, this is not an entirely new virus. The coronavirus has been around for a long time and for example, the so-called MERS, the Middle Eastern episode that was associated with camels, had a much higher risk with death as far as when it's spread.

And then the SARS virus, which is another virus that ran many years ago, that was also a coronavirus. So the coronavirus is different from the influenza viruses, but from the point of view of likely progression, think of it as another type of influenza flu virus. My own projections are that this is going to be around for about three to four months. That peak is very dependent on our rate of admission of patients to hospital and the degree of isolation. So just give you an idea.

If the isolation is not carried out, then we expect the peak to occur earlier and that would probably now be in mid-May. If we have a 20% reduction in interaction between people, in other words, isolation has some effect, then the peak will probably be mid-June. If we have a very effective isolation and a 40% reduction of interaction of people, the peak will probably be in mid-August.

Now this is the peak. There'll be lingering rates of infection and on top of that it's unclear how long things will last. Now a big question is the degree of isolation and how long it's carried out. We know from the flu epidemic in 1918, the so called Spanish flu that last three years, that there were three waves. With this epidemic or pandemic now is as it's called, it appears that things are happening more quickly. So for example, China, Hong Kong, Taiwan, South Korea are already expecting or have experienced second waves of infection. So those are things that play into this.

A couple of things about this virus that may be of interest to you, it gains entry into cells to a receptor called the ACE2 receptor. So these little spikes on the coronavirus, the sort of spikes you see in the pictures, they are like little fists. They attach to these receptors.

Now these receptors are very common in the lungs obviously, but also on the heart and other organs to a less extent and that's why they particularly affect the lungs but also can affect the heart in about 7.5% of patients. We also know from what we've seen in China, South Korea and Washington, that patients with cardiovascular disease, and this is mainly coronary artery disease, are more prone to the infection and complications related to it. And obviously people who have lung disease, smokers, vaping, that seems to be also predisposing people to infections.

We also know that our own experience here at the Cleveland Clinic, we have about 30 patients now. That are about half the patients need to be in ICU and be on a ventilator related to the respiratory complications. However, from our experience so far we have only had one patient that has had more extensive support with heart-lung machines.

So that is less often. But we have prepared for that. And if we flatten the curve and you've by now heard of the curve, then we'll be able to manage that from a cardiovascular point of view.

So there were a number of questions that we had. I'll answer some and then I'll pass on to Samir and then also to Marc to answer them.

So one question that comes up is so-called elective surgery. So we worked with the governor here in Ohio and the decision was made that it would be defined as essential versus nonessential. So we here at the Cleveland Clinic have looked over all our patients that we were due to see and tried to sort patients into essential versus non-essential.

Now for essential patients, those are patients that who potentially would suffer organ damage or having symptoms, having pain or where there's risk to life if the patients do not get treated. And we defined that as the next eight weeks. So we have postponed some operations but not all. But if people are having symptoms, then we've recommended that patients undergo surgery during this time because there's obviously some risk if patients do not get treated.

So another question then has become, how do you contact us now? We've been working a lot with virtual visits. Those can be done via computers and potentially FaceTime or telephone. Most of our contact has been occurring by telephone and you're welcome to phone our numbers and our nurse managers will help triaging your situation and at the same time our physicians will be involved with helping on that.

Another question that's come up is how safe is it to come into the Cleveland Clinic and what has happened is everybody who works at the Cleveland Clinic every morning as they come into work, they get tested for their temperature. So we have a thermal scan and to check everybody is first of all a Cleveland Clinic employee and secondly that they are safe to interact with patients.

Let me remind you that our procedures also, people wear gowns and face masks and hats and so from the point of view of spread of infections to patients, that is in very low risk. We've also limited visitors to only essential periods of visitation and Marc can explain fully what that involves.

Another thing that has happened as far as reducing the risk of transmission is that we have banned all travel by our physicians and staff both on a national basis and an international basis. And that's been in place now for a number of weeks. When it comes to visiting patients, there are some restrictions, but we also are flexible when it comes to that issue.

So with that I am going to hand over to Samir to answer some of the questions. One of the ones is these so-called ARB drugs like Valsartan, some of the other drugs and also nonsteroidal drugs. And I'll ask Samir to answer some of those questions. Basically at this time it's unclear, but we are actively enrolling patients in study currently to look at this. But I'll ask Samir to answer some of the questions.

Dr. Kapadia: Thank you Dr. Svensson. I just want to first of all tell everybody that the risk of getting or contacting the virus is quite similar for all the patients. How sick you will get after contacting the virus depends on your comorbidities. So if you can prevent contact, if you can have good distance from the people, wash your hands and take all the precautions. It is not that if you have a heart problem, you're likely to contact the virus more compared to people who do not have heart disease.

So this is an important message. This will give you a little bit more safety in your mind at least to think that you are not at a high risk of contacting the virus. On the other hand, if you do contact the virus, if you have heart problems, especially coronary artery disease as Dr. Svensson mentioned, or if you have heart failure, then obviously your risk of having longterm complications or serious complications from the illness is increased.

Therefore, it is even more important to prevent social distancing and keep the social distancing and prevent the disease from happening. With that said, should we have differences in medications if you are taking ACE inhibitors or ARB medications? There is some data to say that the ACE2 inhibitor is unregulated. Is it true that you should stop taking the medication? No. The Heart Failure Society very clearly mentioned that you should not stop these medications because the harm that you can get from stopping the medication is much more than potential benefit that you may have. You must contact your cardiologist if you have any questions.

In Cleveland Clinic we are doing virtual visits for everybody. So if anybody has a question, even if a new patient or an old patient, we are able to see them as a virtual visit right now even if you are in a different state than Ohio, you can still call us and we can still see you and provide care, even prescribed medications as a virtual visit.

It will require a face to face discussion with some form of video conferencing. But with that we can provide right now a good care to all the patients and answer all your questions regarding all this different things that come to people's mind.

The second thing is that essential procedures in cardiovascular medicine including angioplasties, including valve replacements, pacemakers devices are many. What we say since as you heard from Dr. Svensson that this peak may happen from June to even August. What we are telling people is that if we cannot delay the procedure to prevent the end organ damage, meaning the heart problems or lung problems or we cannot prevent from people from having symptoms, ongoing symptoms, then we should consider them essential if we can wait less than eight weeks. So eight weeks is the term that we are using in our mindset to decide whether this is considered essential or non-essential.

We are currently doing more than 50% of our procedures or roughly 50% of our procedures. We are taking extreme care for all the patients to make sure that they don't contact the virus while they are in the hospital. So we are doing everything possible from the healthcare workers to the visitors to the ancillary services to make sure that it is as safe and as convenient to the patient as possible. Because safety and to some extent convenience are a little bit at contradiction because we cannot have all the patients visit their families at all the times. But we have specific rules and we accommodate patients according to their needs.

And finally, I want to say that all the healthcare workers in Cleveland Clinic are incredibly dedicated to what they do. Everybody is working together in this difficult times, including from the ICU to the inpatient care, to the virtual visits, to the outpatient care, working with different colleagues in different institutions. So we are actually very proud in this difficult time to provide incredible care for your heart problems and feel free to reach out to us anytime and we'll try to accommodate your needs to the best of our abilities.

Dr. Gillinov: We're still doing a fair bit of cardiac surgery because as Dr. Kapadia said, we split procedures, our operations into two categories, essential or non-essential. And cardiac surgery is very often essential, meaning it's lifesaving and reduces symptoms and in many, many cases we can't safely delay an operation, a cardiac surgical operation for two months. So we do operate and we operate safely. We are fully staffed to perform these operations.

Patients ask, "If I have my surgery now will I be at more risk for getting the virus in the hospital?" And our answer is no, because as Dr. Kapadia said, we're screening all of us, the healthcare workers, limiting visitation. So the hospital is actually a very safe place to be in terms of the virus and contagion at this time.

We've been asked by patients who had their heart surgery previously, "Am I now at increased risk?" And you're at no more increased risk of contracting the virus. But if you do get the virus and you have heart disease, you are at increased risk for complications. That said, if you have had a valve repair procedure, for example, mitral valve repair and you have normal heart function, you don't have any problems, no arrhythmias, no heart failure, you're likely at no greater risk than the general population, meaning you're fine, but maintain your social distancing, personal hygiene, washing your hands, don't shake hands, et cetera.

Dr. Svensson: Well thank you for watching this brief summary of our understanding of things. Keep watching what is broadcast from the White House, from your governors and keep in contact with your cardiologists. So thank you for your time and if you have any questions, please reach out to us on our website. There are phone numbers to connect with us and keep safe. Keep your social distance and use lots of hand sanitizer and don't cough on anybody, use the usual etiquette for coughing. Thank you very much.

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