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What the Pandemic Hasn't Changed in Cardiology

Despite all the ways that COVID-19 has changed healthcare—and the list is long—there are many aspects of medicine that haven't altered one bit.

Nor should they, argues Dr. Nicola Cosentino of the Monzino Cardiology Center in Milan, Italy. In a recent roundtable with Ian Rowlandson, Chief Scientist of Diagnostic Cardiology at GE Healthcare, Dr. Cosentino stressed a key point: As much as we should focus on the "new rules" of COVID-19, such as mask wearing, hand washing, and increased diagnostic diligence, we should also hold precious those parts of healthcare that should not change.

"Our life must continue," said Dr. Cosentino, who has treated cardiac patients for COVID-19 in Italy since the outbreak began in early 2020. "The ways we treat our patients must continue in the same way." To him, it's critical that providers do everything they can to reduce the viral spread among healthcare professionals and patients.

Virus or Not, Cardiac Patients Need Care

Dr. Cosentino's thoughts are shared by many providers, including cardiologists. Best practices and recommendations have necessarily shifted amid the pandemic, with new precautions being implemented to protect both patients and providers, but heart problems haven't stopped for COVID-19. Whether patients contract the novel coronavirus or not, many still need specialty care.

Physicians also need to encourage patients to continue seeking care in a timely fashion, even if that means helping them overcome their fears of contracting COVID-19. When Dr. Cosentino was asked what he would have liked to have known before the novel coronavirus gripped Italy, he said that he most wishes he could go back in time to remind patients to listen to their bodies and heed the warning signs of trouble.

"I would have said that patients need to go to the hospital [if they feel] chest pain," he said. "Unfortunately, we saw in the first few weeks a dramatic reduction in ST-elevation acute myocardial infarction patients that was paired with a dramatic increase in out-of-hospital cardiac arrest."

Indeed, those early weeks of the COVID-19 pandemic had many cardiologists worried. "Where have all the heart attacks gone?" said one headline from the New York Times. As it turns out, many individuals were suffering at home without medical care. One JAMA Cardiology study investigating 2020 MI incidence in New York City found a three-fold increase in the number of EMS-involved out-of-hospital cardiac arrests between 2019 and 2020. Another study among Italian patients that was published in the New England Journal of Medicine found similar results, with mortality rates for out-of-hospital death climbing nearly 15 percent between 2019 and 2020.

Lessons from the Pandemic

Dr. Cosentino also remarked on lessons learned beyond patient education, such as the need to focus on early intervention before COVID-19 progresses. As information continues to pour in related to therapeutics and testing, practitioners now have more intel and tools to preempt severe disease, he added.

He noted that coagulopathy was frequent, and in some cases patients had very bad pulmonary vessel thrombosis and ischemia of the legs and arms, with some needing amputation. "If we had known this, we would have immediately given them higher doses of heparin," he said. "Not all patients [need] a high dose of [heparin], but critical COVID-19 patients actually do."

As Dr. Cosentino points out, many corners of the care ecosystem have changed, at least for the foreseeable future. For example, there is stricter adherence to protocols around mask wearing, hand washing, machine cleaning, and infection control.


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Where Do Cardiologists Go from Here?

Going forward, providers will need to be even more vigilant about the potential complications of an active or past COVID-19 diagnosis. Because COVID-19 has been associated with increased risk of acute cardiac injury, including acute myocardial infarction, myocarditis, myocardial infarction, cardiac arrhythmias, and other conditions, quick use of diagnostic tools such as ECG can help cardiac teams stay alert and prevent severe problems. Practitioners should note that the use of hydroxychloroquine comes with its own heart risks and requires careful monitoring to track prolonged QT intervals, especially when combined with antibiotics associated with QTc prolongation.

Close care and surveillance are made more complex with the added risks of COVID-19 in our new reality, so adhering to industry best practices, such as those outlined in these electrophysiology guidelines from Heart Rhythm, will remain critically important.

Will these new rules be in place forever? Time will tell. For now, providers acclimating to the new normal should heed Dr. Cosentino's advice: Cling tightly to what hasn't changed while you adapt to what has.

"We can win this war, and I think we are winning the war," he said. "But we have to respect the rules. We have to treat our patients in the best way. And we cannot give up."