By Richard Korecky, PharmD, BCGP
COVID-19 has profoundly changed the world we live in today and will continue to leave an indelible mark long after the pandemic has ended. One area of concern for both health care providers and their patients is the long-term effect of COVID-19 infection on patients with chronic diseases.
Acute cardiac injury has been a well-documented feature of infection with SARS-CoV-2, which causes COVID-19 among patients requiring hospitalization.
Heart failure, myocardial infarction, acute cor pulmonale, cardiogenic shock, myocarditis, multisystem inflammatory syndrome, cardiac arrhythmias, and sudden cardiac arrest have all been reported in patients with COVID-19 infection.
A lingering question is whether these sequelae of the acute infection will lead to worsening clinical outcomes over time and potentially a chronic disease state.
Pre-existing heart disease such as heart failure, coronary artery disease, cardiomyopathies, and possibly high blood pressure can lead to more severe courses of COVID-19 and, in many cases, increase the risk of death. Retrospective analyses of hospitalized patients indicate that better control of these pre-existing issues before infection with COVID-19 may reduce the risk of mortality and indicators of worsening COVID-19 disease such as ICU admission or mechanical ventilation.
More study is needed to understand the exact relationship between chronic disease control and COVID-19 infection. However, patients who have better control of many chronic illnesses, including diabetes, hypertension, hyperlipidemia, COPD, and heart failure, have lower risks of future disease and adverse clinical outcomes unrelated to COVID-19, such as MI, strokes, cardiac arrhythmias, etc.
Primary care doctors have an essential role in mitigating COVID-19 by taking steps towards improving the health of their at-risk patients. One way to approach this is by implementing a Chronic Care Management (CCM) program that focuses on the ongoing care coordination, treatment, monitoring, and follow-up of patients with chronic heart diseases.
There is significant evidence that well-applied telehealth interventions, including CCM, can improve blood pressure, lipid levels that serve as a biomarker for cardiac event risk, and other clinical measurements such as hemoglobin A1C, a measure of diabetes control.
Clinicians can and should work with patients to discuss and set goals for meaningful health-related behaviors, including lifestyle modifications and dietary changes, that lead to meaningful behavioral changes by patients.
Leveraging the well-established relationship between diet, exercise, and cardiac health is critical for any successful chronic care program treating heart disease patients. Over-reliance on medical therapy alone has led to a generally worsening healthcare landscape for our most at-risk patients as well as the aging population as a whole. PharmD Live’s approach to Chronic Care Management incorporates a holistic perspective to health that empowers patients to become more involved in their healthcare decision-making and take ownership of their health. Patient involvement is critically important in reducing the overall burden of chronic diseases and specifically those regarding chronic heart disease due to the overwhelming effect of the patient-specific variables previously mentioned.
It is important to note that one of the main mechanisms of organ damage by SARS-CoV-2 is clotting, including microvascular clotting. Studies of anticoagulant and antithrombotic use in critically and non-critically ill hospitalized patients effectively reduces the risk of complications, including mechanical ventilation, organ support, and mortality.
It is unknown whether COVID-19 infection in patients who do not require hospitalization causes microvascular clotting of clinical significance. However, using aspirin to treat patients upon confirmed infection is a reasonable strategy for those without contraindication during the acute phase of infection.
While the recent RECOVERY trial concluded that aspirin offered no additional benefit to hospitalized COVID-19 patients and is frequently cited as a reason to avoid the use of aspirin in COVID-19 patients, it is essential to note that by the time of the trial, use of antithrombotic treatment for hospitalized COVID-19 patients, either through full or prophylactic dosing of low molecular weight heparins or heparin, had become the standard of care. Indeed over 93% of patients in this trial were treated concurrently with an antithrombotic agent, limiting the applicability of such data to outpatients who are not on such therapies currently.
This highlights the importance of considering the use of aspirin and potentially other anticoagulant therapies in patients with confirmed COVID-19 infection, especially among those who have other risk factors for coagulopathy. The clotting caused by SARS-CoV-2 is likely multifactorial. Though antiplatelet therapy alone may not prevent all clotting, a simple screening by providers to exclude patients who are most likely to suffer harm from the use of aspirin, such as patients over 85 years old, those who are already taking an anticoagulant, those with a history of GI bleeds or intracranial hemorrhage can reduce the risk of an adverse effect.
The coming years will answer whether or not patients who have recovered from acute COVID-19 will face an increased risk of future heart disease. It is well understood that patients who experience acute cardiac events or chronic uncontrolled hypertension are at a significantly increased risk of developing heart failure, for example. However, there has not yet been enough evidence to positively correlate between mild-moderate COVID-19 infection and future risk of heart diseases. Post-recovery use of aspirin or anticoagulants is likely unnecessary for these patients. Further research can determine any potential clinical benefits and the prevalence of these conditions in those who have recovered from COVID-19 infection to determine what increased risk these patients face.
Primary care providers face fundamental challenges in the acute and post-acute management and treatment of COVID-19 patients. The effect of COVID-19 on heart disease and the known risk factors for severe COVID-19 infection indicate that, as always, prevention and mitigation of chronic heart disease will pay significant dividends in reducing the overall disease burden on patients and physicians and the healthcare system as a whole.
A well-operated and comprehensive Chronic Care Management program is one of the easiest and most effective measures providers can take to improve their patients’ clinical outcomes and become more empowered and engaged in their own healthcare decisions. PharmD Live can help your practice implement a CCM program that will deliver superior results for your patients with pre-existing heart disease as well as for those with other chronic conditions.
Our board-certified clinical pharmacists take time to understand the individual challenges each patient faces in their health care journey. They work with them to develop a tailored care plan while also holding them accountable for their progress towards personal health goals. Contact us today to learn how we can help your practice.
About the author
Dr. Korecky is committed to engaging patients in their health care and empowering them to care for their chronic health conditions. He is a clinical pharmacist and the Director of Clinical Pharmacy for PharmD Live. He explores novel technology uses and believes pharmacists will be the key to coordinating care as healthcare evolves. Dr. Korecky also holds an MBA in Health Care Management from the University of Baltimore. He is a member of the American Society of Consultant Pharmacists.
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