Despite all of the ways that COVID-19 has altered healthcare, many aspects of medicine haven't changed one bit.
Nor should they, argues Dr. Nicola Cosentino of the Monzino Cardiology Center in Milan, Italy. Reflecting on a 2020 roundtable with Ian Rowlandson, Chief Scientist of Diagnostic Cardiology at GE Healthcare, Dr. Cosentino echoed a similar point in 2022 to what he'd said at the start of the pandemic: as much as we should focus on the lessons learned from COVID-19, particularly around infection control and increased diagnostic diligence, we should also hold onto the parts of healthcare that should not change.
"As cardiologists, we still basically do the same things we used to do before, but now we have new tools to do them," says Dr. Cosentino, who has treated cardiac patients for COVID-19 in Italy since the outbreak began in early 2020.
"Telemedicine, CT and echo, virtual teleconferences, and even social media—these all existed before the pandemic, but we've learned how to use them more strategically," notes Cosentino.
Amid the pandemic's hardships, burnout, and losses, these and other tools have helped cardiologists continue care, share important learnings, and diagnose issues more efficiently. After all, heart problems never stopped for COVID-19, and they won't for the next big crisis, whatever that may be. That's why it's critical to look back and review what insights have been gleaned over two years of grappling with the pandemic.
Approaching Acute Patients with More Urgency
One of the most important lessons to come out of COVID-19 has been to urge patients to seek care in a timely fashion, even if that means helping them overcome their fears of doing so. No matter the circumstances, acute problems warrant urgent action, according to Dr. Cosentino.
"During the first and second waves of COVID-19, we saw so many acute cardiac patients dying because they didn't go to the hospital," he reflects.
That lesson came at a tremendous cost. "Where have all the heart attacks gone?" asked one April 2020 headline from the New York Times.1 By now, we know acute patients were suffering at home. 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 2020.2 Another study of 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% between 2019 and 2020.3
Faced with these concerns, cardiologists have learned not only to act quickly, but also to act comprehensively. As a result, diagnostic tools such as CT, echo, and ECG have become more widely embraced than they once were, according to Dr. Cosentino.
Expanding Chronic Care Support and Prevention
Clinicians should be equally conscious of the impacts of chronic disease. Not only do many patients with a prior COVID-19 infection experience long-term cardiac risk, but there may also be another wave coming of chronic patients whose diseases have little to do with the virus itself and more to do with the state of the world during COVID-19.
"During the pandemic, we saw a dramatic decline in cardiovascular prevention because patients were all focused on COVID-19," Dr. Cosentino says. "I think we'll see this translate into a wave of coronary artery disease and heart failure patients in the next five years."
One opportunity he sees to combat this coming problem is through social media. Despite its unwelcome ability to spread misinformation, it has proven itself as an influential public health messaging tool.
"Social media had a positive impact on patients' understanding of what they should do during COVID-19, such as social distancing, handwashing, mask-wearing—all of the rules we knew were important," says Dr. Cosentino. "If we can use social media in the same way to promote cardiovascular prevention—to stop smoking, watch lipid levels, control blood pressure, have a healthy life style (physical activity)—I think we can stave off these impending waves in the next decade or so."
Balancing Holistic and Specialized Expertise
Dr. Cosentino also remarked on the trial-by-fire nature of COVID-19 across the cardiac care continuum, and how, despite the risks of unprecedented burnout, that tumult helped cardiologists stretch outside their specialties to become better, more resilient physicians.4
"In the last 20 years, cardiologists have been super specialized—you have those who take care of acute coronary syndromes, of acute heart failure, of arrhythmias, valvular disease. But COVID-19 equalized the playing field. Everyone did the same work." He sees this as a positive development, "because we were reminded that we're all doctors. We don't have to lose our general expertise as we become specialists. We still have to treat patients holistically."
Still, there is a downside. Young clinicians whose careers started during COVID-19 lost the opportunity to watch colleagues do the more specialized work as the focus shifted to pandemic response. That necessary shift has created an industry-wide training deficit.
"There was so much energy dedicated to publishing scientific insights for COVID-19 that we practically went two years without any other cardiovascular research taking place," notes Dr. Cosentino.
"The industry has lost out on important guidelines for existing providers, as well as specialized education for medical students. That creates a big gap in the preparation of these doctors. No one will give them those last two years back, so we have some catching up to do."
Fortunately, the pandemic did yield one resource that will be helpful here: virtual learning. As international conferences are made more accessible to clinicians anywhere, anytime, cardiologists can help to address these learning curves on-screen.
"With teleconferencing, you can attend world-class educational events in your pajamas," Dr. Consentino says.
Where Do Cardiologists Go from Here?
Beyond these far-reaching lessons, it's important to acknowledge that cardiologists will still be reckoning with SARS-CoV-2 for some time. Going forward, providers should stay vigilant about the potential complications of an active or past COVID-19 infection.
For active infections, two years of data have added more insight into the effects of COVID-19 on the heart. Direct and indirect damage is prevalent, and a Cleveland Clinic survey posits that 40% of COVID-19 patients may have acute cardiac complications.5
These effects can extend to chronic concerns, with an estimated 1 in 4 so-called "long-haulers" experiencing problems such as heart failure, arrhythmia, or chronic inflammation of the heart. Dr. Cosentino suggests that the risks are so great that in future years, COVID-19 could be a clinically relevant part of a patient's health history as a cardiovascular risk factor.
"When someone has had a COVID-19 infection, it's a red flag for a cardiac complication," he says.
Because many of these factors translate to increased risk for acute cardiac injury, including acute myocardial infarction, myocarditis, cardiac arrhythmias, and other conditions, quick use of diagnostic tools such as ECG can help cardiac teams stay alert and prevent severe problems. These tools offer even more utility in the context of telemedicine, which has expanded its footprint amid COVID-19.
Close care and surveillance continue to come with the risk of COVID-19 infection in our new reality. The warring dynamics between highly contagious variants like Omicron BA.2, vaccines, boosters, and FDA-authorized treatments like Paxlovid have often resulted in a "two-steps-forward, one-step-back" effect.
Will COVID-19 be with us forever? Time will tell. For now, providers should cling to what hasn't changed while they adapt to what has. Even after two years of volatility, Dr. Cosentino's 2020 advice still rings true:
"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. And we are now more prepared in case of a future stress for our healthcare system (another virus or pandemic)."
Where Have All the Heart Attacks Gone? The New York Times. Accessed May 24, 2022. https://www.nytimes.com/2020/04/06/well/live/coronavirus-doctors-hospitals-emergency-care-heart-attack-stroke.html.
Lai PH, Lancet EA, Weiden MD, et al. Characteristics Associated With Out-of-Hospital Cardiac Arrests and Resuscitations During the Novel Coronavirus Disease 2019 Pandemic in New York City. JAMA Cardiology. 2020;5(10):1154. doi:10.1001/jamacardio.2020.2488
Baldi E, Sechi GM, Mare C, et al. Out-of-Hospital Cardiac Arrest during the Covid-19 Outbreak in Italy. New England Journal of Medicine. 2020;383(5):496-498. doi:10.1056/nejmc2010418
ACC Survey: Burnout Rates Double For Cardiology Clinicians Amid COVID-19. American College of Cardiology. https://www.acc.org/latest-in-cardiology/articles/2021/06/01/01/42/feature-acc-survey-burnout-rates-double-for-cardiology-clinicians-amid-covid-19. Accessed May 24, 2022.
Cleveland Clinic Survey: Cleveland Clinic Survey: Roughly 40% of Americans Have Experienced at Least One Heart-Related Issue since the Beginning of COVID-19 Pandemic. Cleveland Clinic. https://newsroom.clevelandclinic.org/2022/02/01/cleveland-clinic-survey-roughly-40-of-americans-have-experienced-at-least-one-heart-related-issue-since-the-beginning-of-covid-19-pandemic/. Accessed May 24, 2022.