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Patients with heart failure have many questions about COVID-19 including their risk for getting COVID, damage to the heart from COVID, information in the news about heart failure medications, concerns about going to the doctor during this time, red flag symptoms, and how patients with heart failure can stay healthy during this time.  Dr. Jerry Estep, Section Head of Heart Failure and Transplantation answers these questions and provides sound advice for heart failure patients during the coronavirus pandemic. 

Additional resources can be found at:
Cleveland Clinic: COVID-19 and Heart Failure
Heart Failure Society of America

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Heart Failure and COVID-19

Podcast Transcript

Announcer:

Welcome to Love Your Heart, brought to you by Cleveland Clinic's Sydell and 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.

Betsy Stovsky, RN, MSN:

All right. Well hello everybody. We're here this morning with Dr. Jerry Estep who is the section head for our section for heart failure transplantation at the Cleveland Clinic. Thank you for being here this morning to answer some questions that we have for our heart failure patients.

Jerry Estep, MD:

Thank you for having me. Delighted to talk about this important issue related to COVID-19 and cardiovascular disease.

Betsy Stovsky, RN, MSN:

The first question is always I think patients are worried if you have heart failure are you more at risk for getting COVID or is it if you get COVID are you more at risk for serious complications?

Jerry Estep, MD:

We certainly appreciate information from China and other countries and information involving here that there are a number of conditions that are associated with being more at risk; older, being in a nursing home, underlying medical conditions like chronic lung disease and serious heart conditions, and the one condition that has been of concern is hypertension and hypertension certainly it can be a common cause for heart failure. But really there's a paucity of information related to heart failure predisposing someone to be at higher risk. So I think it's the latter as it relates to that. If you do get coded, you're at higher risk of getting very sick or having a greater severity of illness. And so we're really promoting and highlighting for those with underlying heart failure.

Jerry Estep, MD:

It is a serious underlying condition and do everything possible to minimize getting sick related to good hand hygiene, social distancing, and staying at home as much as possible. I think that's the key message. We don't want our patients with heart ... we don't want anybody to acquire this illness and get sick, but if you have heart failure, there's a chance of becoming very ill because of this underlying significant condition.

Betsy Stovsky, RN, MSN:

So when we hear patients who are very sick and they're in our ICU does COVID actually damage the heart? Does it cause heart failure?

Jerry Estep, MD:

Yes. Unfortunately COVID-19 like other viruses can cause inflammation in the heart and that can create damage. We can see it when patients are in the hospital by an abnormal EKG it looks like patients are having a heart attack and we check blood work and screen for these heart enzymes and when there's heart muscle injury, these enzymes can be very elevated. And really it's a reflection and in many patients of this inflammation burden, the body's response to the infection, and so patients can develop significant heart failure even in the absence of having heart failure as a risk factor.

Jerry Estep, MD:

And so we are very attentive to understanding those that come in with severe shortness of breath, whether they have cardiac manifestations. And so EKG, monitoring on telemetry to screen for any electrical signals or changes. And in those patients that aren't getting better or have signs of fluid excess, we have a low threshold, actually look at the structure of the heart, its function and size to understand in addition to looking at blood work, whether the heart is involved because that is associated with unfortunately a poor prognosis. But we take aggressive measures to try to help our patients that have or develop heart failure from COVID.

Jerry Estep, MD:

So the answer is yes it can create heart damage and heart failure.

Betsy Stovsky, RN, MSN:

So would you suggest that patients who actually survive a COVID illness, they've been in the hospital, that may be after this is all settled, that they should be evaluated by a cardiologist later to see if there's the damage or if they need to have future care?

Jerry Estep, MD:

Yeah, I think it's a good question. I think those that have the infection should follow the recommendations put forth by the CDC and their local doctors in terms of minimizing distancing from others and take maybe direct care. I think those that were short of breath in the hospital setting, most are likely to have a cardiac evaluation of some sort by EKG or blood work. If those that are hospitalized are getting significantly better and don't have preexisting heart related conditions and are free of shortness of breath, no evidence of a fluid excess, leg swelling, stomach swelling, no chest pain, they're probably okay. Those with underlying heart conditions should follow up with their primary heart providers for continued maintenance of that co-morbidity, whether it's hypertension or another type of heart condition.

Jerry Estep, MD:

I think it will be sorted out if you will during that hospitalization. And so those that are feeling fine and without any other underlying heart condition I don't think they need a run to go see a heart doctor, especially in the context of everything going on. And we're really promoting a virtual platforms to evaluate patients.

Jerry Estep, MD:

I think patients that have had COVID and are hospitalized and sent home and have persistent shortness of breath or a relapse of breathlessness, especially coupled with fluid retention, those patients should seek attention and reach out to their primary care physician, and if they develop severe reoccurring symptoms, rest breathlessness, this sense of doom, they should call 911 and seek more emergent care.

Betsy Stovsky, RN, MSN:

There's been a lot in the news about some of the medications that are cardiac medications, some are actually used for heart failure and people are concerned should they stay on their medication, should they stay on their same doses? What are you telling patients about their medications?

Jerry Estep, MD:

Yeah, that's a very good question. We use these ACE inhibitors and angiotensin receptor blockers or ARBs, these medicines and those with the type of heart failure associated with reduced ejection fraction saves lives. It prolongs survival. And we're advocating not to stop or reduce the dose of these medications because the potential for rebound heart failure is more harmful.

Jerry Estep, MD:

There are concerns about how ACE inhibitors and ARBs may protract or cause greater severity of illness. In terms of this ACE2 receptor that allows as part of the viral entry into cells and whether over-expression is associated with more problems than benefit, there are some theoretical concerns and it's being sorted out and worked on. But the advocacy by the major societies and what we're promoting for our heart failure patients right now do not stop your ACE inhibitor or ARB or heart medications unless you're told to do so by your primary provider and certainly don't reduce the dose either because there's more risk of having rebound heart failure problems then these other concerns.

Betsy Stovsky, RN, MSN:

There are some concerns from patients about getting lab work or going to the hospital right now, going to see their doctor if they do have an appointment, maybe even there's concern that patients even when they're having symptoms are not seeking care because they're worried about catching COVID if they go to a medical institution. Do you have any advice regarding that?

Jerry Estep, MD:

Yes, that's a very important point. What we're doing to continue to manage our patients that have heart failure is we are doing virtual visits. That's either by the use of a phone call or ideally a platform using a smartphone or a computer so that we have continued interaction to understand the presence or absence of symptoms, the change in symptoms and stability, and we are doing blood work as part of surveillance in select patients to ensure the electrolytes are stable or to screen for any kidney problems. And so I think right now for those patients that are relatively stable, defined as no worsening of their symptoms, most importantly connecting with your provider is going to be a key.

Jerry Estep, MD:

I think what patients can do to help us help them if you will, is learn how to use these platforms, smartphone or a computer to participate in telehealth visits and keep track of missed visits and work with your team. Certainly maintaining social distancing. And if these measures are relaxed, there'll be an opportunity for in-person visits.

Jerry Estep, MD:

So what we're advocating for is we really tailor it to the individual patient. I want to highlight that patients that have progressive shortness of breath, feeling worse, needing to be in the hospital because of heart failure and persistent or refractory fluid retention. You couple that with blood work that can be done safely, closer to home or a campus associated with your primary provider. Where we're seeing worsening kidney function ... heart failure is a serious underlying condition and the chances of dying with progressive, severe heart failure defined by worsening persistent symptoms and what I've mentioned, there could be a 25 plus percent for some patients in excess of 30% of dying from the heart failure condition over the next several months to a year, year and a half.

Jerry Estep, MD:

And so for some patients, the risk of heart failure and death is greater than the risk of acquiring COVID-19 and dying from COVID-19. So even given the unfortunate current pandemic, we want to still be very sensitive to bringing in select patients to have inpatient care that they need. So certainly working with your provider to get guidance on how that can be best achieved.

Jerry Estep, MD:

We have a low threshold to test COVID-19. It can be difficult in some patients that have shortness of breath, how much is respiratory, how much is heart failure. So certainly there's a lot involved in terms of that decision making and working with your provider, but understanding if you're having these symptoms is the most important. I think at first start these virtual or telehealth platforms are very helpful. But if you're having severe shortness of breath and suffering, the sense of doom, you should call 911 and the providers will help guide you and most importantly position them to take care of you.

Jerry Estep, MD:

That's the messaging we're giving. I think that's a critical question.

Betsy Stovsky, RN, MSN:

Just in a final point where people are at home and trying to quarantine and do everything they can to stay healthy, I know with heart failure a big piece of that is just lifestyle and staying healthy. What are you telling your patients during this time to help them stay healthy and stay out of the hospital?

Jerry Estep, MD:

Yeah, so we're really advocating for staying at home and trying to stay at home as much as possible, and in keeping with the CDC recommendations of wearing a mask if you have to go out, and try to minimize that because heart failure patients are at higher risk to get very sick if they acquire this. And so social distancing, good hygiene and then all the standard recommendations, a low sodium diet, watch fluid intake, importantly, take your medications, ensure you have enough refills so that there's not a lapse where you can have rebound heart failure. If we can minimize changes like that, that would warrant an appropriate hospital admission we're better off and so that's really what we're highlighting.

Betsy Stovsky, RN, MSN:

Well thank you so much for spending time with us this morning. This was a lot of very important information for patients with heart failure.

Jerry Estep, MD:

Thank you very much. I would love to highlight that the HFSA has a coronavirus, COVID-19 resource center that patients and providers can look at that detail a lot of the information we highlighted today. Thank you for having me, my privilege.

Betsy Stovsky, RN, MSN:

Bye-bye.

Jerry Estep, MD:

Bye-bye.

Announcer:

Thank you for listening. We hope you enjoyed the podcast. We welcome your comments and feedback. Please contact us at [email protected] Like what you heard? Subscribe wherever you get your podcasts or listen at clevelandclinic.org/loveyourheart.

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