Of the long-term
effects that the heart can have on our bodies, that we are still learning
about, the one which might perhaps raise the most grievous concerns would be how
and to what extent the virus can impact our hearts.
Newspoint has spoken to Dr Andrew Cassar Maempel, a Visiting Lecturer at the University of Malta and consultant cardiologist at Mater Dei, who raised some concerns on the lasting cardiovascular damages caused by COVID-19.
What impact does COVID-19 have on the heart of affected patients and is it direct or indirect damage?
COVID-19 can cause heart problems in multiple different ways:
It can cause direct injury to the heart muscle causing an inflammation of the heart known as myocarditis or indirect injury due to hypoxia (low oxygen levels) in the setting of acute severe respiratory syndrome; COVID-19 can also damage the lining (called the endothelium) of the heart arteries which be the precursor of a blood clot with occlusion of the heart artery resulting in a heart attack (myocardial infarction) It can cause a stress type of heart attack known as stress cardiomyopathy; Finally, COVID-19 has also been associated with abnormal rhythms of the heart known as arrhythmias.
Any of the above COVID-19 complications may result in the heart muscle becomes weak with resultant symptoms of heart failure such as shortness of breath and ankle swelling.
Do individuals who suffered a mild bout of COVID-19 a few months ago, need to worry about their heart health now?
More than 85% of patients who are infected with COVID-19 may be asymptomatic or have only mild symptoms which usually resolve within 2 weeks. Despite this, a recent research paper Outcomes of Cardiovascular Magnetic Resonance Imaging in Patients Recently Recovered From Coronavirus Disease 2019, published in July in JAMA Cardiology noted that if a cardiac MRI is performed on patients who had COVID-19 a few months prior, up to 78% of patients had some involvement of the heart and 1/3 of patients had evidence of ongoing cardiac inflammation or even scar. We do not yet know whether these patients will develop symptoms or cardiac complications in the future.
How is COVID-19 affecting consultations between patients and their doctors?
Social distancing is the most important way of decreasing spread of COVID-19 infection.
However, doctor-patient interaction is also an important part of assessing and treating patients. A balance has to be found so as to decrease risk of infection while at the same time proving adequate care to patients. Telemedicine, in which patients are called (audio+/-video) to discuss their condition or give results, is being encouraged by authorities. This may be adequate if the patient is stable, but in some situations in person interaction to allow thorough examination (while still taking precautions) is necessary.
Are individuals with cardiac conditions delaying going to hospital out of fear of COVID-19? Is this leading to increased heart problems or death?
Yes, unfortunately many patients who are having serious cardiac issues are not presenting themselves to the hospital on time due to fear of contacting COVID-19.
In March/April 2020, when Malta was in partial lockdown, the number of patients presenting to the cardiac catheterisation suite at Mater Dei Hospital with an acute heart attack was about 50% less when compared to the same months in 2019. Also, many patients who presented to the hospital did so after waiting for a considerable time at home before presenting to the hospital. It was also noted by the Emergency Department that the number of outside hospital cardiac deaths was increased.
This phenomenon was also well described in multiple other countries around the world and is part of the collateral damage that is being caused by the pandemic. Not seeking timely life saving treatment such as getting a stent to open up a blocked heart artery during a heart attack results in increased morbidity (such as heart failure) or even mortality. I thus urge patients who experience symptoms associated with a heart attack to seek help immediately.
The hospital is a very safe place to be and every patient is screened for coronavirus upon arriving in hospital and patients who test positive for coronavirus are kept segregated from other patients.
With many elective surgeries postponed, there is a huge backlog of patients – have any adverse outcomes in these patients-in-waiting been detected?
Unfortunately, many elective surgeries had to be postponed during the partial lockdown so that the hospital could prepare better for the COVID-19 pandemic. These surgeries were elective and thus most of them could be postponed without significant adversity to the patient. This does not mean that the patient did not suffer. For example, if a patient required a knee replacement due to severe arthritis and this was postponed, this resulted in prolonged pain for the patient but it was reasonable to postpone the surgery during the pandemic since it does not affect longevity. Emergent surgeries such as percutaneous coronary interventions (stents) for patients having acute heart attacks continued even during the pandemic. Elective surgeries are now occurring at similar rates to the pre-COVID-19 era. All patients are swabbed to ensure the patients are COVID-19 negative before taken to the operating room.
How will cardiology practice change in the future due to COVID-19?
It is uncertain at this stage if there will be a change in cardiology practice in the future. It is possible that the number of patients with heart failure, as a result of cardiac patients not seeking medical care or due to heart complications in patients who contacted COVID-19, may increase in the near future. This will increase the burden on the cardiology services both in the inpatient as well as outpatient departments.