11.1 Impact of COVID-19 on Cardiovascular Disease

These proceedings summarize the educational activity of the 16th Biennial Meeting of the International Andreas Gruentzig Society held January 31-February 3, 2022 in Punta Cana, Dominican Republic

Faculty Disclosures     Vendor Acknowledgments

2022 IAGS Summary Document

Statement of the problem or issue

The care of patients with cardiovascular disease has been dramatically affected by the COVID-19 pandemic with both direct and indirect effects (Figure 1).^1,2

The COVID-19 virus has a variety of deleterious influences on endothelium, the vasculature, and the myocardium, mostly related to proinflammatory and prothrombotic effects. These lead clinically to increases in deep venous thrombosis, pulmonary emboli, stroke, and acute myocardial infarction (AMI), generally occurring within the first month of active disease. Patients with a history of cardiovascular disease and those with cardiovascular risk factors (especially hypertension and diabetes) are at increased risk for complications of COVID-19, including longer hospitalizations and higher mortality. Myocardial injury, based on elevated troponin levels, occurs in 20%-40% of hospitalized COVID-19 patients and is associated with further increased risk of mortality. Interestingly, microthrombi leading to STEMI or NSTEMI has been a novel presentation of COVID-19. Patients with sustained symptoms or “long COVID” appear to have increased risk of microvascular dysfunction.

The indirect effects of the COVID-19 pandemic have been just as dramatic, with disruption in clinical care pathways and other healthcare processes. Public health measures taken to prevent spread of the virus, including cancellation or deferral of elective procedures and in-person appointments, along with restrictive visitation policies and lockdowns, led to barriers in care delivery on the one hand, as well as reluctance of patients to obtain both elective and emergent cardiovascular care on the other hand. For example, there was a 25%-40% reduction in patients presenting with STEMI throughout the world, coupled with significant time delays at every step for those who did present to the hospital. This resulted in a significant increase in mortality in patients with STEMI, as well as higher rates of out-of-hospital cardiac arrest, cardiogenic shock, and late complications (including papillary muscle dysfunction, ventricular septal and free wall rupture, and LV thrombus). Vaccines were developed quickly and were highly effective, but vaccines also can have cardiovascular complications including pericarditis, myocarditis, and thrombosis, in particular with younger patients and those with previous COVID-19 infection.

Gaps in knowledge

Although the response within the cardiovascular community to the COVID-19 crisis has been admirable, large gaps in knowledge remain: the ideal treatments for each stage of the disease; the appropriate timing of vaccines and boosters; the appropriate response to new viral variants; and the efficient adaptation of healthcare delivery for all patients. Clearly, there has been a substantial financial and psychological impact on cardiovascular training programs, cardiovascular practices, hospitals, and our patients. Perhaps the most challenging issue of all is the ongoing healthcare worker shortage, which includes all healthcare professionals including nurses and physicians, and which is most severe in high acuity-of-care settings, including the cardiac catheterization laboratory, surgical suites, and cardiac and other intensive care units.

Possible solutions and future directions

The Society for Coronary Angiography and Interventions (SCAI) has played a key role in the response to the COVID-19 pandemic in the United States in a number of important ways. Some of these include: (1) Surveys investigating the impact on interventional cardiology training programs, cardiac catherization laboratories, and interventional cardiology patients; (2) key position papers and guidelines, including an initial response regarding best practices for cardiac catheterization laboratories (published in March 2020³),and guidelines for the treatment of acute myocardial infarction (published in April 2020⁴), both of which have stood the test of time;³ (3) development of the North American COVID myocardial infarction (NACMI) registry (started in March 2020), which is now the largest registry for COVID patients with STEMI, and has provided unique insights into understanding this high-risk group;^5,6 (4) an online COVID-19 resource page for interventional cardiology practices; and (5) the “Seconds Still Count” public health campaign, designed to advocate to the population about the safety of both hospitals and physician offices, and encouraging patients to seek cardiovascular care quickly when needed. These efforts illustrate creative ways in which professional societies can respond to healthcare challenges like COVID-19. Still, in conclusion, we are likely not done with COVID-19 yet, and the cardiovascular community will need to continue to adapt.

References

1. Henry TD, Kereiakes DJ. The direct and indirect effects of the COVID-19 pandemic on cardiovascular disease throughout the world. Eur Heart J. 2022;43(11):1154-1156. doi:10.1093/eurheartj/ehab782

2. Atri D, Siddiqi HK, Lang JP, et al. COVID-19 for the cardiologist: basic virology, epidemiology, cardiac manifestations, and potential therapeutic strategies. JACC Basic Transl Sci. 2020;5(5):518-536. doi:10.1016/j.jacbts.2020.04.002

3. Welt FGP, Shah PB, Aronow HD, et al. Catheterization laboratory considerations during the coronavirus (COVID-19) pandemic: from the ACC’s Interventional Council and SCAI. J Am Coll Cardiol. 2020;75(18):2372-2375. Epub 2020 Mar 19. doi:10.1016/j.jacc.2020.03.021

4. Mahmud E, Dauerman HL, Welt FGP, et al. Management of acute myocardial infarction during the COVID-19 pandemic: a position statement from the Society for Cardiovascular Angiography and Interventions (SCAI), the American College of Cardiology (ACC), and the American College of Emergency Physicians (ACEP). J Am Coll Cardiol. 2020;76(11):1375-1384. Epub 2020 Apr 21. doi:10.1016/j.jacc.2020.04.039

5. Garcia S, Dehghani P, Grines C et al. Initial findings from the North American COVID-19 Myocardial Infarction Registry. J Am Coll Cardiol. 2021;77(16):1994-2003. doi:10.1016/j.jacc.2021.02.055

6. Garcia S, Dehghani P, Stanberry L et al. Trends in clinical characteristics, management strategies and outcomes of STEMI patients with COVID-19. J Am Coll Cardiol. 2022;79(22):2236-2244. Epub 2022 Apr 4. doi:10.1016/j.jacc.2022.03.345