Dr. Kohli On COVID

The height of the COVID-19 pandemic impacted all sectors of health care, especially cardiology. In this interview, DocWire News Medical Lead Payal Kohli, MD, FACC, spoke about what cardiology services were most impacted, about the long-term effect of COVID on the heart, and about whether or not the health care community is prepared for a future pandemic.

DocWire News: How has the COVID-19 pandemic impacted the cardiology space?

Dr. Kohli: It’s unbelievable what we’ve lived through the last few years. And the impacts of what’s happened, I think, are going to be felt for decades to come. So, we know that they’re both direct and indirect impacts that have happened as a result of COVID-19. So, the direct impacts are the people who had COVID and recovered from it. And some of them had cardiovascular complications during their illness, and some may have complications such as long COVID because we know that this virus doesn’t just work on the heart muscle. It can also work on the blood vessels, as well. So, it’s really a systemic virus, not just a respiratory one. And then of course, there are the indirect effects, and some of which I believe we can’t even start to appreciate or wrap our head around. But we know that there were huge disruptions in the delivery of healthcare, as well as people taking care of themselves.

At the height of the pandemic, which cardiology services were the most impacted?

During the last couple of years, there was a significant rise in mental health problems and substance abuse, obesity, and deconditioning. And then of course, a lot of people were afraid to go to the doctor to get their chronic disease conditions managed. So, the American Heart Association and others have actually released data that, in the coming years, we’re really going to be looking on a new curve of the pandemic. And that’s what I like to call the prevention curve because preventive health really took a backseat. Even in fact, people in the midst of their heart attacks, some of them didn’t go to the hospital and seek care. So, a small heart attack turned into a big one with lots and lots of complications.

It’s so interesting that you asked that question because there were the services themselves. And then there were also the workforce for the service because we know that provider burnout was at its all time high. And we call it the great resignation, which very much applies to medicine, as well. We lost a lot of the medical workforce as a result of the pandemic. So, there’s actually data from the British Medical Journal that’s looked at the first month or so after lockdown. And what we see is that there was a 53% reduction in cardiology and ward and CCU admissions, which is incredible if you think about it. You basically cut the number of patients going to the hospital or the ICU by 50%, and there was actually a 40% reduction in the number of diagnosed heart attacks. Now, that doesn’t mean the number of heart attacks went down, it just means we weren’t doing as good a job at diagnosing those heart attacks, particularly diagnosing them early.

We also know that, during the peak of the lockdown, there was a 93% decline in face to face visits. Now of course, some of that was offset by virtual visits or telemedicine, but we don’t believe that the offset, or the impact, of the virtual visits made up for the missed pieces of the care that we saw in the face to face visit. So, that was really during the peak of the lockdown. But even after we shifted our life back to the endemic phase and started coming back to normal, we know there were a number of things that impacted patient care. For example, supply chain shortages. And we’re talking about shortages of substances like contrast, which is used in the cath lab in the midst of a acute ST-elevation MI or non ST-elevation MI. It’s a must have type of medication.

It’s not something you can live without. And there were shortages, and some cath labs had to go on diversion and such because they didn’t have enough contrast to do their procedures. Similarly, with outpatient medications, I have a number of patients who weren’t able to get their blood pressure medicine on time. They weren’t able to get their CPAP machine because there was a back order for CPAP. So, the domino effect that’s been created by the disruption of our life that we’ve had is really going to continue to manifest itself, I think, in the next several years and may still be very much a part of our daily clinical practice.

Do we have an idea about the long-term effect of COVID on the heart?

We’re just starting to learn. I think we’ve done a tremendous amount of research in the last couple of years to really understand what the effects are. The virus is changing a bit. So, we do know that the original Wuhan variant may have had different effects compared to the Delta one, which was very severe, compared to the present Omicron one, which does appear to be milder. We know that the ACE2 receptor, which is the receptor that the virus uses to get inside cells, is present on blood vessels. It’s present on myocardial tissue, so on heart muscle. So, that certainly increases the risk. But I think even past the initial infection, which for a lot of people now in the setting of being vaccinated and boosted and having Omicron is relatively mild, we are seeing that up to one in three people can have signs or symptoms of long COVID, which can include cardiac manifestation.

So, in my office, I see several patients every week who are coming in for workup of long COVID, and we can see conditions like dysautonomia, exercise intolerance, prolonged fatigue, and some of this can occur even months and months after the initial index illness, suggesting that it’s not just post viral syndrome. Now, I’m really excited about the advent of the bivalent vaccines because I do believe that vaccination is the key to minimizing the impact of some of these long term complications, particularly the long term cardiac complications that some of us really are challenged as to how to even treat because there’s not that many great treatment options.

Do you think that the healthcare community is prepared for a future pandemic? 

I would love to say that we are, but unfortunately I feel like we’re not. And forget about future pandemics. We just had a little mini test with the recent Monkeypox outbreak that we’ve had in our community to see how we can respond to future such infectious disease conditions. And I hate to say it, but I think we’ve failed the test as a community. Now, as individual providers, I would say we absolutely are much more prepared than we ever were before having lived through the COVID-19 pandemic. I also think that patients themselves are much more educated, they’re much more knowledgeable, they ask the right questions, and many of them are attuned to their preventive health. So, I think as individuals, we’ve come a long way. But I think as a community, as a whole, as a country, even as an international community, we need to really do better in terms of improving universal access, trying to really figure out how we can change our national responses to be ahead of the virus, and actually be proactive rather than following what the virus is doing and being reactive to what’s going on.