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Based on reports from China, we know that most COVID-19 patients (about 80%) will develop mild flulike symptoms, including fever, dry cough, and body aches that can be managed at home. 20% will develop more serious symptoms, such as pneumonia requiring hospitalization, with about a quarter of these requiring ICU-level care.
Initial reports focused on the respiratory effects of COVID-19, such as pneumonia and difficulty breathing. But more recent literature has described serious cardiovascular complications occurring in about 10% to 20% of hospitalized patients.
Someone with pre-existing heart disease who becomes ill with COVID-19 may suffer a heart attack or develop congestive heart failure. This rapid worsening of cardiovascular health is likely due to a combination of the severe viral illness and its increased demands on the heart (fever causes rapid heart rate, for example), compounded by low oxygen levels due to pneumonia and increased propensity for blood clot formation. In addition to the increase in these heart problems, a more unusual condition called myocarditis has also been observed in COVID-19 patients.
Some COVID-19 patients who appear to be having a heart attack are instead suffering from marked inflammation of the heart muscle, called myocarditis. The electrocardiograms in these patients show changes suggestive of a major heart attack, and blood tests reveal elevated levels of troponin, a cardiac enzyme that is released when heart muscle is damaged. The heart muscle becomes weak, and dangerous heart rhythms may develop. Severe injury to the heart muscle, as measured by troponin levels, has been strongly associated with increased risk of death in people with COVID-19, according to a review published in JAMA Cardiology.
It is not clear whether myocarditis is due to a direct effect of the virus on the heart muscle, or whether it is due to an overactive immune response to the virus, so doctors do not yet know how best to treat these patients.
About 10% of patients with pre-existing cardiovascular disease (CVD) who contract COVID-19 will die, compared with only 1% of patients who are otherwise healthy. Increased risk has also been seen in people with high blood pressure (hypertension) and coronary artery disease (CAD), though it is not clear why. Some experts have suggested that the missing link may be the use of certain blood pressure medications called angiotensin converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs).
ACE inhibitors and ARBs are among the most commonly prescribed medications for the treatment of high blood pressure. These medications have been proposed as a possible factor in the increased incidence of COVID-19 in people with high blood pressure. That’s because of the observation that the coronavirus attaches to the ACE2 receptor, which is found in lung and heart tissue. People who take ACE inhibitors and ARBs produce increased numbers of these receptors, raising the question of increased susceptibility to infection.
However, ACE2 has been found to protect against viral lung injury in mice. And a study is ongoing to test whether losartan, an ARB, may protect patients infected with COVID-19.
As of today, there is insufficient evidence of either harm or benefit. The American College of Cardiology, American Heart Association, and Heart Failure Society of America therefore recommend that we neither stop the use of ACE inhibitors and ARBs in patients already taking them, nor prescribe them anew.
There are no special protocols for higher-risk cardiac patients to prevent COVID-19 exposure, but these individuals should be especially careful to follow the CDC recommendations, including frequent handwashing and physical distancing.
It is also important to stay up to date on the flu and pneumonia vaccines, because any illness can weaken the body’s ability to fight off COVID-19. Heart patients should avoid close contact with children 18 and under, because although children rarely develop serious illness from COVID-19, they may be asymptomatic carriers who can transmit disease to vulnerable family members.
In addition to these recommendations, it remains vitally important to exercise (outdoors when possible, keeping safe distance from others), get enough sleep, manage stress, and eat a balanced diet. These healthy habits will not only bolster the immune system to help ward off COVID-19, but will help prevent CVD progression in the longer term. After all, once the pandemic has subsided, we will still have heart disease to contend with.
For more information, listen to our podcasts and see our Coronavirus Resource Center.
The post How does cardiovascular disease increase the risk of severe illness and death from COVID-19? appeared first on Harvard Health Blog.
Depression affects about 20% of Americans in their lifetime, and is one of the leading causes of disability. The rates of depression are even higher in those with cardiovascular disease (CVD). Depression affects 38% of patients undergoing coronary artery bypass graft surgery, and the risk of depression is three times as high in patients who have experienced a heart attack compared with the general population. Depression also makes it much more likely that CVD patients will be readmitted to the hospital and report heart-related symptoms.
Yet much of the time, symptoms of depression in those with CVD go unrecognized. And as we all know, if we don’t identify a problem it’s very difficult to find a solution.
Depression matters to cardiologists because patients with both depression and CVD have increased mortality rates, and significant reductions in their quality of life. Depression can often stem from feeling increased stress and lack of control regarding a chronic health condition like heart disease. In other cases, depression may already exist, and continue or worsen in response to CVD.
By affecting mood, sleep, and energy, among other things, depression can greatly impact a person’s ability to optimally manage their CVD. For example, depression makes it less likely that someone will take their medications as prescribed. And depression can make it very difficult to adhere to lifestyle recommendations such as eating a healthy diet or getting regular exercise.
In addition to affecting behaviors, depression is also associated with physiologic mechanisms that help to explain the poor prognosis in patients with CVD. These mechanisms highlight the connection between the brain and the heart.
For example, depression can cause autonomic dysfunction, which negatively impacts resting heart rate, heart rate variability, and blood pressure. Depression can affect underlying inflammation, leading to elevated levels of potentially harmful circulating inflammatory molecules. Depression can also worsen insulin resistance, leading to further inflammation and diabetes. And depression can affect platelet reactivity, making blood stickier and, in turn, making a recurrent or new heart attack more likely.
In April 2019, the Journal of the American College of Cardiology published a review in which they discussed a practical approach to the screening and management of depression in patients with CVD.
The review is a practical resource for cardiologists, which can help with early identification and improved management of patients with depression and CVD. By implementing screening practices, doctors can start a conversation about symptoms and their impact on health outcomes.
A multidisciplinary approach to symptom assessment is likely most effective, and involves the patient, the cardiologist, and the primary care physician (PCP). In some cases, mental health professionals, pharmacists, and care coordinators might also be involved.
The American College of Cardiology recommends that screening take place at routine office appointments with both cardiologists and PCPs. Screening questions you may be asked include:
Your doctors are looking for symptoms of a depressed mood, diminished pleasure in activities, low self-esteem, sleep disturbances, changes in appetite, loss of energy, and difficulty with concentration.
If your cardiologist or PCP does not ask you about symptoms of depression, you should feel comfortable volunteering this information.
Thankfully, multiple proven treatment options exist for depression, and doctors and patients should discuss a personalized treatment plan. Exercise is an effective antidepressant therapy for those with mild or moderate depression. Exercise has been shown in multiple studies to have a significant impact on depression and cardiovascular outcomes.
With my cardiology patients who are experiencing depression, I typically recommend participating in an organized exercise program. If patients have had a recent heart attack they are eligible to enroll in a cardiac rehabilitation program. For all other patients, I recommend joining a program at their local gym.
Cognitive behavioral therapy (CBT) is another great nondrug way to treat depression. CBT is a form of therapy designed to change ingrained patterns of negative thoughts or behaviors. Medications can also be used, either alone or in combination with exercise and CBT.
The post Recognizing and treating depression may help improve heart health appeared first on Harvard Health Blog.
Update: On April 1, 2020, the FDA requested manufacturers to withdraw all prescription and over-the-counter (OTC) ranitidine drugs (Zantac, others) from the market immediately, due to the presence of a contaminant known as N-Nitrosodimethylamine (NDMA). Although the FDA did not observe unacceptable levels of NDMA in many of the samples they tested, they have determined that the impurity in some ranitidine products increases over time and when stored at higher than room temperatures. As a result of this recall, ranitidine products will no longer be available for prescription or OTC use in the US.
The FDA is also advising consumers taking OTC ranitidine to stop taking this medication, including any unused ranitidine medication they may still have at home. Other FDA-approved OTC medications are available to treat heartburn. Patients taking prescription ranitidine should speak with their doctor about other treatment options before stopping the medicine.
As anticipated, recall of the popular heartburn medicine ranitidine (Zantac) has expanded. But we still have more questions than answers.
As I mentioned in my original blog post on this topic, the online pharmacy Valisure, which originally alerted the FDA to the issue, found what they called “extremely high levels” of the probable cancer-causing substance N-nitrosodimethylamine (NDMA) in ranitidine products.
The FDA has indicated that its own preliminary testing has detected low levels of NDMA in ranitidine.
The FDA has clarified that the testing method that found the “extremely high levels” of NDMA applied high heat, at a level much higher than normal body temperature. In other words, the testing did not reflect typical conditions under which the medication would be stored or taken.
The FDA is asking all companies that manufacture ranitidine, as well as other similar medications (both H2 blockers, the class of drugs to which ranitidine belongs, and proton-pump inhibitors, or PPIs, a different class of drugs used for similar conditions), to test their products using lower heat closer to normal body temperature. So far, there is no indication that these other products are affected; the FDA is likely asking for these tests only as a precaution.
As of now, the FDA has allowed ranitidine to remain on the market. Still, some manufacturers have issued voluntary recalls and some pharmacies have pulled it off the shelves.
The FDA has not yet released the results of its own tests of ranitidine. But they previously estimated the likely impact of NDMA found in another class of medications, called angiotensin receptor blockers, on the risk of cancer. That estimate provides some context for the current circumstances.
Angiotensin receptor blockers, including the drug valsartan (Diovan), are used to treat high blood pressure and other heart conditions. They were recalled beginning last year due to the presence of NDMA and other related impurities. The FDA estimated that, if 8,000 people took the highest dose of valsartan containing NDMA every day for four years, there would be one additional case of cancer over the lifetimes of these 8,000 people.
Currently, we do not know how the amount of NDMA found in ranitidine compares to the amount found in valsartan.
Until we know more, the best course of action if you are taking ranitidine is to talk to your doctor about whether treatment is still needed. For some conditions, the benefits likely outweigh the risks. Although some ranitidine products remain available, consider alternative medications such as cimetidine (Tagamet) or famotidine (Pepcid) if you need long-term treatment.
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