In this Q&A, Jay Khambhati, MD, cardiology fellow, Tinamarie Desmarais, RN, clinical research nurse, Kathleen C. Traynor, RN, MS, FAACVPR, co-director and Pradeep Natarajan, MD, MMSc, co-director of the Cardiovascular Disease Prevention Center, describe how patients at risk for cardiovascular disease can stay healthy during the COVID-19 pandemic.

Are patients with cardiac issues at a higher risk from COVID-19?

First, we should clarify terminology. The novel virus is named SARS-CoV-2. Emerging literature indicates that many individuals can be infected by SARS-CoV-2 and have no symptoms.

SARS-COV-2 infection with symptoms is called coronavirus disease 2019 (COVID-19). Symptoms of COVID-19 can vary from being mild and safely managed at home to severe and critical requiring hospital admission.

While our understanding of COVID-19 continues to evolve, patients with cardiovascular disease (CVD) do not necessarily appear to be at a higher risk of becoming infected from SARS-CoV-2 itself. Most patients who become infected with SARS-CoV-2 will either not have symptoms or have a relatively mild set of symptoms such as dry cough, sore throat, fevers, chills and fatigue. Nearly 80% of patients diagnosed with COVID-19 will recover without requiring advanced medical care. However, nearly one out of every six patients who have COVID-19 develop more serious symptoms such as a new or profound shortness of breath and/or chest tightness. The key difference is that among those infected with SARS-CoV-2, those over 70 years old and those diagnosed with 2 or more chronic conditions may develop a more severe illness and may be at a higher risk of death. There is particular concern that CVD risk factors, including hypertension (high blood pressure) and diabetes mellitus, are associated with increasing likelihood of more severe COVID-19. Therefore, extra caution and vigilance is required for patients with CVD and these risk factors. Nevertheless, the majority of patients with underlying cardiac conditions will fully recover from COVID-19. In some cases, patients with underlying cardiac disease may develop cardiac complications as a result of the virus, such as worsening signs of heart failure (sudden weight gain, abdominal pain/swelling, extra swelling in the feet and difficulty breathing when lying flat). 

Are there any extra precautions that patients with cardiac issues should be taking?

By following local state and U.S. federal guidelines, along with the most up-to-date CDC recommendations, we can all do our part to prevent the spread of SARS-CoV-2. Pillars of COVID-19 prevention include:

  1. Regularly using soap and water or an alcohol-based rub to wash your hands for at least 20 seconds
  2. Cleaning high touch surfaces
  3. Practicing physical distancing (at least six feet from others
  4. Avoiding touching your face
  5. Following good respiratory hygiene (i.e., covering your  cough or sneeze and discarding your tissue paper into a proper trash receptacle)
  6. Utilizing masks when physical distancing is challenging

Critical public health strategies to follow during the COVID-19 pandemic also include:

  1. Staying home as much as possible
  2. Avoiding contact with anyone having suggestive symptoms (sore throat, cough, fever or new shortness of breath)
  3. Self-isolating if you develop mild symptoms that can be managed at home

Current SARS-CoV-2 tests are not perfect. If your test is negative but you have suggestive symptoms, you may still be diagnosed with COVID-19 and your doctor may still recommend self-isolation. Ideally, you should isolate yourself from uninfected family members.

The virus can survive on surfaces for a few days and individuals who do not show symptoms may be contagious with the virus. Non-perishable items or those in a container that are brought to the home should ideally be kept aside for at least a few days or wiped clean with sanitizing wipes. Perishable items need to be washed before storage.

Your commitment to practice the recommendations above can help us all decrease the spread of the virus and save lives. If patients develop significant coughing and difficulty breathing, disorientation or confusion, chest pain or pressure, severe lightheadedness, fever or any other concerning symptoms, please call 911 and seek immediate assistance from emergency medical personnel.

How can patients best continue their heart healthy efforts in the COVID-19 era, given the changes in daily routines and certain services no longer being available?

Several centers targeting CVD prevention or risk factor modification, including cardiac rehabilitation programs, athletic centers, fitness classes and gyms, have transitioned to virtual and home-based options in order to adhere to principles of social distancing.

The COVID-19 era can serve as a unique opportunity for you to focus on developing or maintaining heart healthy habits. To begin, we encourage you to start by setting small, achievable lifestyle goals that will improve your modifiable risk factors from the American Heart Association’s (AHA) Life’s Simple 7, which include:

    1. Manage blood pressure
    2. Control cholesterol
    3. Reduce blood sugar
    4. Get active
    5. Eat better
    6. Lose weight
    7. Stop smoking

Through careful preparation or purchasing of meals, you should choose to follow a healthy dietary pattern rich in vegetables, fruits, whole grains, lean vegetable or animal protein, fish, seeds and nuts. Paying close attention to calorie intake, while most often avoiding calorie-dense, nutritionally poor options (sugar-sweetened beverages, excessive red meat, saturated fats, trans fats and prepackaged foods high in sodium and refined carbohydrates), can facilitate healthy weight loss/maintenance and management of cardiovascular risk factors. You should also focus on efforts to stay well hydrated, by drinking water and other non-sugar beverages. Given new challenges in food access related to the pandemic, our nutritionist at the Cardiovascular Disease Prevention Center is available for virtual consultations to help with heart-healthy meal planning.

Furthermore, to achieve the current recommendations of 30 minutes of moderate physical activity daily/150 minutes weekly, you can walk outside and utilize web-based programs to engage in physical activity. Home fitness equipment can be helpful here. Work on sitting less and take frequent breaks from the computer. Stair climbs can serve as a time-efficient approach to maintain fitness. You can maintain strength using your own bodyweight with push-up and sit-ups. If you have an advanced cardiac condition, you should customize a fitness regimen with their health care providers. Play time with family and pets as well as dancing can also be enjoyable strategies to maintain physical activity. Lastly, if you are a Massachusetts resident and have CVD, talk to your doctor about eligibility for cardiac rehabilitation to help achieve your physical activity goals at home and improve your mood. If you are eligible for cardiac rehabilitation, then you could participate in the new virtual Cardiac Rehabilitation Program developed by the Cardiovascular Disease Prevention Center.

Avoiding harmful coping strategies such as new or increased tobacco use, heavy alcohol use or overeating during this period is important to maintain a healthy lifestyle.

If routine checkups are delayed or postponed, what can patients do to stay healthy?

Given the risk of exposure to the virus in health care settings, a number of hospitals and private health care institutions and doctors’ offices across the country have postponed routine health care visits, or converted visits to video or telephone health care visits. During this period, communication between patients and their doctors is key for continued monitoring of chronic diseases(s), safe medication management, and prescription refills is of critical importance.

How can Telehealth appointments help? How can a doctor evaluate patients digitally in a way that will protect their health?

In the short term, telehealth (video or telephone) appointments allow patients to keep in close touch with their physicians and other health care staff. From both a primary care and a cardiovascular perspective, if you have obesity, coronary artery disease, diabetes, high blood pressure, atrial fibrillation or heart failure, you can use a home blood pressure cuff and weight scale to log your heart rate, blood pressure and weight in a health journal. In some cases, an over-the-counter pulse oximeter and home thermometer may provide helpful clinical information for the healthcare team conducting your telephone or virtual visits. The additional measurements from home will allow your healthcare team to provide you with individualized recommendations for your health.

If you develop symptoms that are new, concerning or potentially life threatening, you should call 911 and utilize routine emergency services. For urgent or emergent health conditions, it is critical that patients do not avoid contacting healthcare services due to the current COVID-19 pandemic. Healthcare facilities are adhering to strict protocols to prevent transmission of SARS-CoV-2 in these facilities. If you have a medical emergency, it is imperative that you seek emergent medical care.

Should patients continue taking their current medication?

There were early concerns that certain medicines (blood pressure medications such as angiotensin converting enzyme inhibitors [ACEi] and angiotensin receptor blockers [ARB]) may predispose to SARS-CoV-2 infection because a related protein, ACE2, allows for SARS-CoV-2 infection. However, there is also some data indicating that ACEi and ARB medicines may actually protective. To date, all cardiovascular professional societies (including the American College of Cardiology and American Heart Association) recommend that patients prescribed ACEi or ARB medicines remain on these medicines.

Given the general relationship between multiple CVD risk factors and risk of more severe COVID-19 symptoms, it is particularly important to maintain optimal CVD risk. As such, you should continue to take your current medication as prescribed and should confirm your provider prescribes enough medication (typically 90 days) for long-term control medications, including inhalers, insulin, medication for diabetes, anti-platelet therapies, cholesterol medications and anti-hypertensives (blood pressure medication). Based on current recommendations, you should continue taking their angiotensin-converting enzyme inhibitor/angiotensin receptor blocker (ACEi/ARB) medications. Any concerns regarding medications should be directed to your healthcare provider prior to any medication changes or discontinuation.