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Stay-At-Home Orders; Heart Injury and COVID-19: It’s TTHealthWatch!

TTHealthWatch is a weekly podcast from Texas Tech. In it, Elizabeth Tracey, director of electronic media for Johns Hopkins Medicine, and Rick Lange, MD, president of the Texas Tech University Health Sciences Center in El Paso, look at the top medical stories of the week. A transcript of the podcast is below the summary.

This week’s topics include the impact of stay-at-home orders, taking care of sequelae of mild and moderate COVID, giving acute health problems a miss, and cardiac complications of COVID.

Program notes:

1:18 Staying away from the hospital even with acute issues

2:18 Patient avoidance, lost health care insurance

3:18 Facilities are stressed

4:15 Cardiac injury in COVID

5:15 If troponin is positive

6:15 More studies in Covid heart injury

7:00 Guidelines for primary care management of post-COVID

8:00 Not necessary to test for virus

9:02 Home oxygen monitoring for breathlessness

10:05 Elderly with more severe consequences

10:20 Stay-at-home order impact

11:20 Would have had 220% higher case rate

12:20 Prison populations

13:22 End


Elizabeth Tracey: Are people coming to the hospital for anything other than COVID?

Rick Lange: Cardiac injury in patients with COVID-19.

Elizabeth: What are the long-term sequelae of COVID-19 infection?

Rick: And do stay-at-home orders decrease the rate of COVID infection and fatalities?

Elizabeth: That’s what we’re talking about this week on TT HealthWatch, your weekly look at the medical headlines from Texas Tech University Health Sciences Center in El Paso. I’m Elizabeth Tracey, a Baltimore-based medical journalist.

Rick: And I’m Rick Lange, President of Texas Tech University Health Sciences Center in El Paso, where I’m also Dean of the Paul L. Foster School of Medicine.

Elizabeth: Rick, I’d like you to give us just a really brief update, if you would, on what’s going on in El Paso. Of course, all of us know that this is a hotspot, in fact, the hotspot nationally.

Rick: You’re right, Elizabeth. It’s national news and it is a crisis here in El Paso. We have overwhelmed our hospital capacity and we’re stretching staff. Fortunately, we have adequate PPE, but the incidence here and the severity of the disease, how it’s affecting the community has really been overwhelming. I appreciate everybody’s thoughts, prayers, and concerns. We’ll get through this working together, but it’s a very difficult time right now.

Elizabeth: Indeed, and so of course we’re talking all about COVID this week, unsurprisingly, and now that we’re experiencing this surge nationally. Let’s turn to JAMA Internal Medicine. I served it up as, “Gosh, is anyone going to the hospital for anything other than COVID?” These are two research letters and an editorial that were taking a look at admissions at different places in the country while all of this COVID has been going on.

The first of them I’m going to cover is this retrospective study of admissions to four hospitals in the New York area, the Langone Health System, between March and May of this year. There were about 3,600 non-COVID-19 hospitalizations during that time. They compared that to 2018 and 2019 and that’s a dramatic reduction.

They took a look at 20 different conditions and they said, “What is the thing that people are essentially not coming to the hospital for?” At the top of the list, septicemia, interestingly, heart failure, acute MI, and strokes.

These authors speculate that the reason for this is multifactorial, including primarily patient avoidance of emergency care because they are concerned about having COVID-19 or being exposed to it, lost healthcare insurance, and increased threshold for hospitalization by clinicians.

Then they do have one sort of positive glimmer, which could be changes in patient lifestyle and self-management in this context of social distancing that could be fairly effective. The next one looked at the same thing, but just four conditions, at Stanford in a comparison with New York, and again identified significant drops in daily caseload of four common medical emergencies. There could be a huge impact in that non-COVID-attributable, but COVID-related death, if people are not coming to the hospital when they really need to come.

Rick: We reported previously, Elizabeth, exactly on this issue. There are excess deaths associated with COVID infection, some of which aren’t directly related to the infections. They are due to the avoidance of care.

Some of that’s related to concerns about being in the hospital. Some of it is, we’re trying to keep people out of the hospital when facilities are stretched, as they are in El Paso right now. Some people have lost their incomes or have lost their insurance. Some are caring for kids at home.

We’ve approached it from a number of different perspectives and the story is still the same. People need care. If they don’t get it, there is excess mortality associated with it.

Elizabeth: I would just reiterate what we’ve also talked about before, that at least from my seat in the bleachers I feel a good deal safer at the hospital than I feel elsewhere.

In fact, on Saturday, I had a conversation with a patient who really was saying he just really wanted to get out of there. I said, “Why?” He said, “Because I’m worried I’m going to get infected.” I thought, “Oh my. This isn’t the place where that’s going to happen.”

Rick: Interestingly enough, Elizabeth, we’ve tracked the infections on our campus family. 98% of them were infected outside of the campus, in the community, not in the hospital setting. As you mentioned, the hospital right now is one of the safest places to be.

Elizabeth: So, which of your two would you like to turn to?

Rick: Let’s talk about what I teed up as cardiac or heart injury in patients with COVID-19. This was a multicenter cohort study of seven hospitals in New York City and in Milan, Italy, of patients that were hospitalized with COVID, and they also had an echocardiogram, and they had blood tests.

Among these 305 individuals, what they did identify was if you were hospitalized and you didn’t have any myocardial injury, and your echo was normal, your in-hospital mortality was 5%. If you had any evidence of heart injury at all, your mortality was increased. It was particularly increased in those that had myocardial injury by blood test and an abnormal echo. Their mortality was 32% in a hospital.

What does that say? If you have a COVID infection and you have evidence of heart injury, and a severe echo abnormality, then your mortality is increased.

Okay. Here’s what it doesn’t tell us. It doesn’t tell us how often that happens. Does everybody need an echocardiogram? This was eight different hospitals in Italy and New York, so not everybody had an echocardiogram. We really don’t know how common it is.

I do think, though, that if someone’s troponin is positive, which is evidence of myocardial injury, it would make sense to get an echocardiogram. The other thing it doesn’t tell us is what they died of or how we in fact can improve their outcome, and so a lot of things that aren’t known. I don’t want people to think, “Oh, gosh. Everybody that has a COVID infection has heart damage and it’s going to be a serious thing.” This study doesn’t tell us that. It just says if you do have heart injury and an abnormal echo, it increases your in-hospital mortality.

Elizabeth: Hmm. First of all, let’s mention that this is in the Journal of the American College of Cardiology. I’m wondering about … There is something that I’ve asked you about before, but I’m not sure that we’ve really discussed it, and that is, “In the setting of other infectious diseases, have we been as vigilant looking for these cardiac outcomes?”

Rick: No. In fact, Elizabeth, we only do it in people that have symptoms and their primary symptoms are chest pain or shortness of breath. Virtually everybody with COVID infection has shortness of breath and/or chest pain, so it’s much more prevalent than, in fact, with the flu, for example, or the common cold, and we know both of those can affect the heart as well.

We’re probably doing more studies in COVID viral infections than others, and the other is there’s obviously been news surrounding heart injury, and so people are more aware of it, so we’re probably getting more studies than we would in other viral infections.

Elizabeth: I’d ask you to go out on a limb just a little bit and say, if you were a betting man, what would you say about the persistence of these cardiac abnormalities if someone survives, but they do have them during an acute COVID episode?

Rick: I don’t think we have enough information, Elizabeth. In my experience, with most viral infections, there’s not long-lasting heart injury. It does happen occasionally and it may be more common with COVID, but overall, the vast majority of patients with COVID infection don’t have long-lasting cardiac or heart effects.

Elizabeth: You gave me a beautiful segue into the British Medical Journal. This is actually a set of guidelines for people in primary care for the management of post-acute COVID-19 infection, not severe COVID-19 infection. That’s been covered elsewhere in the critical care literature. This is for all those folks who present with it who just are going to be referred back to primary care, may have had a mild or a moderate infection, and they base this on a number of studies that they had.

What they’ve discerned is that about 10% of people, of all comers, experience prolonged illness after COVID-19, which I thought was really kind of surprising. Some had serious sequelae, thromboembolic complications … Let’s call them less serious, but maybe more troublesome over the long term — fatigue and breathlessness are pretty persistent with a lot of these folks.

They say something that, again, I thought was a little surprising. That if you have a patient who presents with all of this, it’s really not necessary to have a positive test for COVID-19. The clinical history is really enough.

They did have some data that they are using in this, a number of studies as well as this UK COVID Symptom Study using a smartphone app, and they asked people to record actually what’s going on with them. Some of these mild or moderate cases of COVID-19 may be associated with long-term cough, a low-grade fever, fatigue, and a lot of that can be relapsing and remitting.

If you have a breathless patient, you should exclude anemia, but not do a whole bunch of other kinds of studies and investigative tests to kind of see what’s going on with it. A comprehensive approach is important, in social and psychosocial support, as well as the support of the physician that it’s going to get better, things are okay for the most part, and trying to help people to just be fine with that. And potentially — and I’d like to hear your opinion about this — home oxygen monitoring for people who are complaining of breathlessness.

Rick: I’m surprised that only 10% have persistent symptoms that last for weeks because in the hospitalized patients as many as two-thirds of those have persistent symptoms for a month or two. But they’re looking at all individuals, not just hospitalized, everybody that’s had COVID infection, and the vast majority don’t get hospitalized.

Their point is well-taken, which is these symptoms, unless they’re worsening, are part and parcel of the disease and they’ll go away. Let’s not do over-investigations. Let’s not do referrals to specialists when it’s really not necessary. There are certain circumstances where they do feel like you need to do it, if there is a condition is worsening.

With regard to breathlessness, they say most of the time it’s fine. But if the person’s worried, then they can have a home oxygen monitor, a little device that fits over your finger. By the way, for women, you’ve got to take your fingernail polish off. Your finger should be warm. Now, if someone’s breathlessness gets worse, that certainly needs to be examined.

Elizabeth: They also note that because we have more severe disease in older patients, those who survive are at high risk for sarcopenia, malnutrition, depression, and delirium, so those are pretty important things to follow up, I think.

Rick: They are. And they also mention is don’t forget that these people have comorbidities that need to be managed, so their blood pressure and their diabetes. We can’t keep our eye off that ball while we’re recovering from COVID-19 infection.

Elizabeth: Let’s hope that we’re going to have a whole lot more people in this category. Let’s turn to your final one. That’s in JAMA Network Open.

Rick: This is particularly relevant because here in El Paso we actually have a curfew and a stay-at-home order that was just implemented this past week as a result of the increasing COVID infections. The real question is, “Does that really work?”

These authors attempted to address that by doing a cross-sectional study. They used daily state-level data on COVID-19 cases and tests and fatalities. This is data acquired from all 50 states, except for Washington and the District of Columbia. They used the variations in the timing of imposition and lifting of these stay-at-home orders, and even the fact that some states did not impose a stay-at-home order. This is all really a very natural experiment to estimate the association of stay-at-home orders with cumulative case rates and subsequent fatalities. The stay-at-home orders were associated with both a reduction in cumulative cases and a reduction in fatalities.

Let’s put some numbers forward. If there were no stay-at-home orders over this time, they would have had 220% higher cumulative case rates and a 22% higher cumulative fatality rate. This confirms previous data we’ve talked about.

Now, there’s one interesting sidelight here as well. They said, “Listen, we hear that African Americans have a higher case fatality rate, and is that so?” When they looked at areas of the country that had higher proportions of African Americans, they did have higher case rates and higher fatality rates, even when they adjusted for many of the things that you and I would normally adjust for, things like poverty, asthma, prevalence of diabetes, and whether they were in an urban or rural setting. Even despite that, it looks like African Americans had a higher case rate and a higher fatality rate.

Elizabeth: Yeah. That’s something that, again, I feel like we do not have the answer to that. We do not have a complete picture and it’s something that we really need to discern what it is that renders them more susceptible.

Rick: It is, Elizabeth, and some people want to say there is a biologic, there may be something, and that’s a possibility, but there are still things we haven’t looked at. We haven’t looked at whether they’re insured or uninsured. Where do they live? What are their working conditions? Is there disproportionate representation of African Americans in prison or detention centers where it spreads as well? There is still a lot of social considerations that we haven’t addressed.

Elizabeth: I would just note that there was a Lancet study just yesterday that was looking at multigenerational households and established that when older adults live in a multigenerational household, they are more likely to get COVID and more severe disease. I wonder if that might be a factor also, and even in your population.

Rick: It’s certainly a factor in our population and it may be in African Americans. The other big elephant in the room is, “Do we provide culturally competent healthcare to these African Americans?” There are a lot of things that we don’t know.

Elizabeth: On that sobering note, I’m going to keep you in my prayers and meditations that you remain well, and that you’re able to achieve the best outcomes for everybody in El Paso.

Rick: Thank you very much, Elizabeth, and everybody that’s listening, for your prayers, your concerns, and your thoughts. Y’all listen up, and make healthy choices.