By Dr Malar Velli Segarmurthy / Dr Kalaashini Ramachandran / Professor Dr Moy Foong Ming / Professor Dr Noran Naqiah Hairi

As soon as the pandemic was declared, the health and scientific community has worked round the clock for a better understanding of this deadly virus.

In contrary to the common myth, COVID 19 doesn't just affect the lungs alone but has devastating effect on our heart with potential long-term effects. Research have shown that there is a mutual relationship between COVID 19 and cardiovascular diseases (CVD).¹

This infection can either worsen underlying CVD or precipitate de novo (new) cardiac complication. 

Globally, there are about 1.7 billion people with at least one underlying health condition, including cardiovascular diseases (CVD), and this escalates the risk of heart complications, cardiovascular events, and mortality among those infected.²

Patients with underlying medical conditions such as hypertension, diabetes mellitus, myocardial injury and heart failure, have shown to have approximately five times higher risk of severe COVID 19 and mortality rates as compared to those without prior CVD.

The survivors too have high chances to develop cardiovascular complications post-recovery. About 87% of the COVID deaths in Malaysia in 2020 had at least one underlying medical condition with hypertension (61.4%), followed by diabetes mellitus (41.3 %).³

Hypertension is the most common complication reported followed by acute cardiac injury and arrhythmia.⁴

While most patients might recover completely, few might continue to experience symptoms after their initial recovery; an aftermath of being very ill, prolonged inactivity and spending weeks convalescing in bed.

Fulminant myocarditis, a clinical condition of diffuse cardiac inflammation often leading to death have been reported among few within weeks after discharge and normal viral load.⁵

These issues put a heavy burden on the already congested health system in our country. Proactive health service is needed to ensure patients with underlying non-communicable diseases (NCDs) as well as those with a risk of post-COVID 19 cardiovascular complication are adequately cared for.

This will benefit both the population as well as decongest the healthcare system, by preventing unnecessary hospital admissions and cut cost in expenditure, as well as prevent the burnout of health workers.

In order to ensure our COVID -19 patients with either underlying or new onset cardiovascular complications to have a better outcome, some practical recommendations should be on board based on the general guidelines from the World Heart Federation:

1. COVID 19 patients should be managed based on their severity so that patients with moderate or severe disease are admitted to a separate ward for closer monitoring.

2. Patients should be informed and educated on the lingering symptoms and warning signs like fatigue, shortness of breath, cough, joint pain, palpitation, chest discomfort and to seek immediate medical attention if these worsen.

3. High risk patients upon discharge should have a repeat echocardiogram within three months and follow up for a minimum period of 6 months with a regular follow up at their local government clinic.

4. Encourage healthy lifestyles irrespective if it's before or after COVID infection (such as stop smoking, be physically active, consume healthy and balanced diet) to reduce the risk of developing cardiovascular events that can make them vulnerable to severe form of COVID or to assist patients with post COVID infection have a better quality of life.

5. Patient recovering from COVID can benefit from physical therapy and breathing exercise.

Patients with underlying CVD diseases are 'clinically vulnerable'. The healthcare system is currently overburdened; hence prevention is better than cure.

Primary care service should be empowered to reach-out to those who are vulnerable. Self-quarantine has an impact on practicing a healthy lifestyle.

Empowering the population and encouraging good health seeking behavior can improve their quality of life, reduce the congestion of our healthcare system and avoid the devastating effect of this disease. The ones who are at risk should be actively involved in online awareness campaigns and via other feasible medias for those who do not have access to online platforms.

Apart from that a proper triage system should be established in the primary care setting to identify and refer those who are in need for further care without delay. General Practitioners and primary care doctors in the "Klinik Kesihatan" should also be trained to monitor the COVID 19 survivors with potential cardiac complications post- discharge.

Prevention and post-discharge monitoring are vital to ensure their quality of lives are maintained.

This should come along as a shared responsibility by both the healthcare system and the population. Let us do our part and care for your heart because our health is our real wealth.

Reference:

¹ Corrales-Medina, V. F., Alvarez, K. N., Weissfeld, L. A., Angus, D. C., Chirinos, J. A., Chang, C. C., Newman, A., Loehr, L., Folsom, A. R., Elkind, M. S., Lyles, M. F., Kronmal, R. A., & Yende, S. (2015). Association between hospitalization for pneumonia and subsequent risk of cardiovascular disease. JAMA, 313(3), 264–274.

² Dhainaut, J. F., Claessens, Y. E., Janes, J., & Nelson, D. R. (2005). Underlying disorders and their impact on the host response to infection. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America, 41 Suppl 7, S481–S489.

³ KAOS, J. O. S. E. P. H. (2020, November 23). Covid-19: About 87% of those who died in M'sia had underlying health condition, says Health Ministry. The Star.

⁴ Corrales-Medina, V. F., Alvarez, K. N., Weissfeld, L. A., Angus, D. C., Chirinos, J. A., Chang, C. C., Newman, A., Loehr, L., Folsom, A. R., Elkind, M. S., Lyles, M. F., Kronmal, R. A., & Yende, S. (2015). Association between hospitalization for pneumonia and subsequent risk of cardiovascular disease. JAMA, 313(3), 264–274.

⁵ Honka, H., Solis-Herrera, C., Triplitt, C., Norton, L., Butler, J., & DeFronzo, R. A. (2021). Therapeutic Manipulation of Myocardial Metabolism: JACC State-of-the-Art Review. Journal of the American College of Cardiology, 77(16), 2022–2039.

(Dr Malar Velli Segarmurthy, Dr Kalaashini Ramachandran, Professor Dr Moy Foong Ming, Professor Dr Noran Naqiah Hairi, Public Health Department, Universiti Malaya Medical Center.)