• 29 Jun 2020
  • 14 min 32
  • 29 Jun 2020
  • 14 min 32

In this episode, NPS MedicineWise medical adviser and GP Dr Anna Samecki talks to Natalie Raffoul, clinical pharmacist and Cardiovascular Risk Reduction Manager at the Heart Foundation about the link between cardiovascular disease (CVD) and COVID-19.

They discuss the cardiac manifestations of COVID-19, the recommendations around antihypertensives, and some of the ways health professionals can encourage patients to seek out chronic disease management and preventative care.

Further reading and links

Transcript

Voiceover:

Welcome to the NPS MedicineWise Podcast, helping health professionals stay up to date with the latest news and evidence about medicines and medical tests.

Anna Samecki:

Hi and welcome. My name's Anna. I'm a medical adviser for NPS MedicineWise and I'll be your host for today's podcast. As you might be aware, our last few episodes have been focused on issues surrounding medicines and medical tests in light of the COVID-19 pandemic. Today, we'll be looking specifically at the topic of cardiovascular disease and the impact that COVID-19 has had on its management. And I'm pleased to announce that we're joined today by Natalie Raffoul from the National Heart Foundation. Hi, Natalie.

Natalie Raffoul:

Hi, Anna. Thanks for having me.

Anna Samecki:

Yeah, look, thank you so much for your time today. Can you tell our listeners a little bit more about yourself?

Natalie Raffoul:

Sure. I'm a cardiology or clinical pharmacist by background. So I used to work in the hospitals and the cardiology wards and I'm currently the cardiovascular risk reduction manager at the Heart Foundation. And prior to this, I was at NPS MedicineWise as the cardiology and diabetes clinical lead. It's a small world, huh?

Anna Samecki:

It is. Thanks again for joining us. We're lucky to have you on. So NPS MedicineWise recently collaborated with the National Heart Foundation on a COVID-19 webinar that focused on cardiovascular disease. The webinar recording is now available online, and some interesting discussion points came up around heart health in the context of this pandemic. So to start us off Nat, would you kindly summarise some of the issues that were raised in that webinar?

Natalie Raffoul:

Yeah, sure. Well, I think it was an interesting discussion. We sought to unpick some of the challenges and areas of improvement for managing cardiovascular disease during the COVID and maybe even in the wake of the COVID-19 pandemic. I think the key issues that came through were being able to understand the connection between COVID-19 and cardiovascular disease and some of the cardiac manifestations of the infection itself. We had a good meaty discussion about ACE inhibitors and angiotensin receptor blockers or ARBs and their connection to COVID-19 or perhaps some of the speculation around that. And I think we also brainstormed some fantastic strategies to stay connected with our cardiac patients during this time, and not only offering them some of the new relevant medicine-related policy changes, for instance, being able to offer them that home delivery of medicines, but also just ways to ensure that we're reaching them during a time where more and more people are perhaps staying at home. So it was an all-around good discussion. And I think it was great to have experts like yourself onboard to brainstorm with.

Anna Samecki:

Awesome. Thank you, Nat. So you touched on something that is quite important and hoping to elaborate on that a little bit further. What can you actually tell us about the link between COVID-19 and cardiovascular?

Natalie Raffoul:

Yeah, sure. Well, I think this was probably one of our biggest concerns when the pandemic struck, so to speak a few months ago and especially initially there was a lot of data coming through that showed the vulnerability of cardiac patients to COVID-19 and particularly the severe consequences of the infection. So, here at the Heart Foundation, that was probably one of our biggest priorities, to firstly, better understand what that connection looks like and then also to support patients living in the community with cardiovascular disease. And what we've actually found is that the emerging data points to a higher vulnerability of these patients to some of the most severe consequences of COVID-19 infection. So, they're more likely to be admitted to an ICU if they are infected and they're also more likely to die as a consequence of COVID-19.

And the case fatality rate is something like fivefold higher in people with cardiovascular disease compared to the overall COVID-19 infected population. So that was worrying to begin with. But there's lots more information on that by the way, in the most recent consensus statement that the Cardiac Society and the Heart Foundation published recently in the MJA. So there'll be links to that with this podcast, but have a look at the real detail on that. But the other important part, so that's one thing, the vulnerability of the patients to severe consequences, but then the other side of that is the actual cardiac consequences of the infection. So I think a lot of us were focusing on COVID-19 as a respiratory disease or a respiratory infection, but perhaps we weren't giving enough attention to the fact that it also has the potential to cause damage to the heart or have cardiac consequences, worsening existing heart conditions or create new cardiac issues.

Anna Samecki:

Exactly.

Natalie Raffoul:

And so the top ones related to COVID-19 are probably to do with the ventricular dysfunction. We're seeing a lot of acute cardiac tissue injury, things like myocarditis or endocarditis in hospital settings. Heart failure, just like any other respiratory infection, heart failure worsens with COVID-19. And we're also seeing ventricular arrhythmias and ECG changes in patients that are diagnosed with COVID-19.

Anna Samecki:

It's very interesting, but on the flip side, we also, I guess, need to consider that and be mindful of the fact that some of the drugs being used to treat COVID-19 can also have cardiac effects such as long QT. And further to that point, I guess, one of the other big themes that came through on the webinar was this concern around ACE and ARBs and whether they should be continued or stopped. So Natalie, would you mind telling us what the consensus is regarding the use of these medicines and what the National Heart Foundation's position is?

Natalie Raffoul:

Yeah, sure. I think, look, Anna, I think this was probably one of the biggest medicine-related issues that came through, well, maybe second to the hydroxychloroquine drama. But it was big. And when I say that, I don't just mean in the medical media or the medical world, our Heart Foundation helpline had almost doubled the number of calls during COVID-19. And one of the key issues that came through was people calling up asking, "Do I stop my blood pressure lowering medicines?" because of all that they had heard in the media and things like that. So it was certainly, a bit of an issue and you could imagine questioning the safety and value of ACE inhibitors and ARBs, the pillars of how we manage heart failure, hypertension, heart disease.

So, I mean, the audience probably knows, but there was that earlier speculation around the COVID-19 virus potentially being able to enter the cells by binding to human angiotensin and converting enzyme or the ACE2 receptor. And, animal studies suggest that ACE inhibitors and ARBs, they actually may upregulate the ACE2 receptor, expression of that receptor. And so theoretically, medications that upregulate those receptors will increase susceptibility of COVID-19 infection. That was the speculation or the hypothesis.

But what we know now quite clearly is that there's no current clinical data to show that COVID-19 disease severity or susceptibility is different in people taking ACE inhibitors or ARBs, so that's really important. I'm not talking about animal studies. In human clinical trial, there's nothing there that is compelling of a high quality. In fact, I think just recently in May, there were three studies published in the New England Journal of Medicine that provided further evidence to support this hypothesis that actually, there's no connection between COVID-19 and ACE inhibitors and ARBs. Those studies have their inherent weaknesses, but it's reassuring to see that we're just getting more and more emerging data to show that this connection is not really valid.

So yeah, so leading bodies, the Heart Foundation, the Cardiac Society, and the National COVID-19 Clinical Evidence Taskforce have all come out really strongly and said, "Look, don't change the way you use ACE inhibitors or ARBs. Continue to use them where they're indicated. And don't forget that these are well-established medications that we do have evidence of the value of their impact in things like heart failure, hypertension, and coronary heart disease. So don't cease them, please."

Anna Samecki:

Great advice there, Nat. I guess the last issue to raise today is that of chronic disease follow-up and the drop in patients presenting for chronic disease management and preventative health. So from the National Heart Foundation's perspective, why is this concerning and what can health professionals do to encourage patients to return for that management?

Natalie Raffoul:

Yeah. Look, I'm glad you brought this up because I think as things progress with the pandemic and we see perhaps, the funding of that curve of restrictions easing across the country, these kind of indirect consequences of COVID-19 are just going to become more and more important for us to tackle. And, as you've alluded to, the biggest issue in this space is the drop in people really just not coming in for visits, face-to-face visits. Whether it's a GP consult, whether it's walking through the front door of their community pharmacy, whether it's getting their blood tests from their pathology center, all of that, we've seen an all-around drop-in visits. And if you take something like preventative health assessments or screening and focus let's say on CVD risk assessment through something like the heart health check, we'll see something really significant, a 60% drop in heart health checks in April compared to the previous month.

So screenings are really taking a big hit, understandably. We were probably a lot more focused on caring for the acute and the people that are diagnosed. But as restrictions start to ease, I think our biggest challenge is going to be able to really reengage with that cohort of patients. And the way we can do this I think it differs depending on what the practice is set up to do, whether it is a GP practice or indeed a community pharmacy or otherwise. But I think it's probably going to be more about using telehealth where we can, as much as we can to reach our vulnerable patients, particularly now that the telehealth items allow for chronic disease management support. I think continuing to use that, that's going to be really, really important.

The other absolutely critical things going to be to reassure patients that face-to-face visits are actually safe and may be necessary. And so wherever there's a physical examination needed, they do have to come in. If they need a blood test, they do have to come in. And that I think has already been started by groups like the RSCGP, who've got a bit of a campaign going on about that, so it's good to hear.

But the last tip or if not plea that the Heart Foundation has is that we probably have to be a bit more creative in how we're integrating cardiovascular care into our day-to-day routine consultations. For instance, we heard in the webinar, for example, Barbara had some great tips while she was running her flu clinic and bringing people in for their flu vaccine, which thankfully, lots of people have done that. As part of that, she was also taking their blood pressure, and taking their other cardiovascular risk factors, doing a bit of a quick assessment and saying, "Hey, you want to come back in a month and we'll do your heart health check," or we'll do something else or whatever else was relevant for them. So I think integrating stuff into existing consults is going to be really important.

And then the other, in a feedback we're hearing from community, is actively recording people and it's probably going to be the way to go. A lot of practices, especially as restrictions ease, and perhaps, if they're not involved in COVID-19 testing, they're waiting for work. They're sitting there waiting for people to come in and see them. So active recall, I think, is going to be another key initiative. So, now's the time to consider, okay, if you've got patients 45 and up, and they don't have heart disease, recall them in for a heart health check. Let that be your gateway to screening a whole number of chronic diseases and set up that ongoing risk management plan with your patients, for example. So yeah, active recall is going to be important.

Anna Samecki:

Awesome. Thank you, Nat. That was very comprehensive. And look, thank you so much for your time today, Natalie, and thanks to everyone for listening. For more information, or to even watch the National Heart Foundation webinar recording, please visit the NPS MedicineWise or National Heart Foundation website. There will be a link at the bottom of this podcast as well. Also, if you have any questions about or suggestions for our podcast series, please reach out to us via Twitter or LinkedIn. Thanks again.

Voiceover:

For more information about the safe and wise use of medicines visit the NPS MedicineWise website nps.org.au.