How to manage a patient with COVID-19 and heart failure
Dr Kieran Walsh, Clinical Director, BMJ
Patients with heart disease have faced multiple risks during the COVID-19 pandemic. Patients with coronary artery disease or hypertension are at increased risk of developing a severe infection. The pandemic has also meant that certain services for patients with heart disease may be unavailable - because the health service is so busy or sometimes because of infection prevention and control reasons. Lastly, COVID-19 can directly affect the heart – by causing myocarditis, the result of thromboembolic disease, or myocardial infarction. These problems can impact any patient with heart disease, but patients with heart failure may be especially vulnerable.
There are no straightforward answers to any of the problems that patients with heart failure may face – but DeFilippis and colleagues have written an important paper on how we should consider them. (1)
One of the first issues that they analyse is that of ACE receptors, ACE inhibitors, and angiotensin II receptor blockers (ARBs). One of the early scientific discoveries about COVID-19 is that the virus that causes the infection enters cells via the ACE2 receptor. This led to some early concerns about these drugs. However, the authors summarise the current state of knowledge in this area – that is, that the “use of ACE inhibitors/ARBs is not associated with increased rates of COVID-19 infection or risk of severe disease.” They also reiterate the current advice that patients currently taking these drugs for hypertension or heart failure of other potential indications should continue on them – unless there is a clear reason for them to stop.
Patients with COVID-19 who become seriously unwell are at increased risk of thrombosis. This can be especially important in patients who already at increased risk of thromboembolism because of heart failure. Some patients with heart failure may already be taking anticoagulants to prevent venous or arterial thromboembolism and, unless new reasons for caution or contraindications arise, patients should continue on these prophylactic medications.
There is also the issue of drugs for heart failure interacting with new and experimental therapies. Some of these new agents can cause prolongation of the QT interval – which may be a pre-existing problem in patients with heart failure. This can then increase the risk of arrhythmia and sudden cardiac death.
There are further dilemmas for certain subgroups of patients with heart failure – such as the need for advanced care planning in those who have end-stage heart failure or patients who have had a transplant who might be taking immunosuppressants.
The article goes a long way in providing answers to the many questions that healthcare professionals might have about heart failure and COVID-19. Inevitably it cannot answer all of them. It also cannot answer questions about how to manage patients with heart failure and COVID-19 who have other comorbidities such as diabetes or depression or dementia. That is what we are trying to do with the Comorbidities Tool from BMJ Best Practice. Heart failure is an interesting case – as most patients with heart failure will have comorbidities. An infection with COVID-19 means that they will then have three or more illnesses. This means that there is a lot of potential indications, contraindications, cautions, and interactions to remember. If we are to offer any support, then it must work at the point of care – so that healthcare professionals are not overloaded with information. We need to give them information where and when they and their patients need it.
1. DeFilippis EM, Reza N, Donald E, Givertz MM, Lindenfeld J, Jessup M. Considerations for Heart Failure Care During the Coronavirus Disease 2019 (COVID-19) Pandemic. JACC: Heart Failure. 2020 Jun 3.
KW works for BMJ which produces the BMJ Best Practice Comorbidities Tool.