The long cardiovascular tail of the pandemic

by: Amitava Banerjee

The countries which have been unable to suppress SARS-CoV-2 infection rate have had to focus health systems and resources on the acute hospitalised phase of COVID-19, particularly in the intensive care unit. However, most hospital care of COVID is not in intensive care, and most COVID patients, even in high-income settings, are not seen in hospital. Moreover, it is now clear that a great deal of the burden of COVID-19 is outside the acute phase. 

Consideration of cardiovascular disease (CVD) has followed the same trajectory, where much of the debate and concern has been about direct effects such as myocarditis and pericarditis. Myocarditis may not be as common as initially thought. Where it occurs, it appears to be mild and usually recovers, based on current literature, but further follow-up and more representative data are required. 

However, the indirect impact of the pandemic on CVD and its care are likely to represent a greater burden for individuals, populations and health systems. A systematic review included 103 observational studies of CVD care during the pandemic. Most studies assessed hospitalisations for acute CVD, e.g. acute coronary syndrome, ischaemic strokes and heart failure. 89% of studies reported reduced hospitalisations during the pandemic compared to pre-pandemic times, with reductions ranging from 20.2 to 73%. CVD and its care needs to be prioritised, especially in times of global health emergency, when we know that underlying conditions such as CVD increase the severity and mortality of COVID-19. This can be achieved by reducing infection rate at population level (a “zero COVID” strategy) which ensures that non-COVID services can be maintained, and education of patients, public and health professionals to recognise and seek help for CVD symptoms. Following acute COVID-19, it has been clear since May 2020, that some patients have persistent symptoms and functional impairment. In 47 780 post-hospitalised COVID-19 patients , four months after initial SARS-CoV2 infection, we showed that major adverse cardiovascular events, chronic liver disease, chronic kidney disease, and diabetes after discharge from hospital were 3.0 (2.7 to 3.2), 2.8 (2.0 to 4.0), 1.9 (1.7 to 2.1), and 1.5 (1.4 to 1.6) times more frequent, respectively, than in a matched control group. Even in non-hospitalised patients, cardiorespiratory symptoms are common and have resource implications in terms of investigations and specialist input. The mechanism of the increased risk of CVD is not clear and needs to be further investigated. However, it is clear that CVD has played a role in the COVID-19 pandemic as a risk factor, a potential long-term consequence and an indirect effect. Therefore, CVD management is crucial during and after the pandemic.