The current COVID-19 pandemic has thoroughly changed how societies and economies function, some with more success than others, but the same cannot be said for healthcare systems. In even the most-developed countries, they nearly succumbed to an increasing number of patients with severe respiratory issues.
Despite clinicians’ best efforts, many succumbed to the disease, with an even greater number of others battling lingering after-effects that are still poorly understood. However, there is also another less recognised non-direct deleterious effect of COVID-19 on patients who have not had the disease, i.e. having been put in second or third place to COVID-19 patients due to the perceived less serious nature of their health issues. Many, particularly cardiovascular patients, have suffered severe consequences as a result.
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The high rates of cardiovascular issues and associated mortality in patients with COVID-19 have prompted some commentators to label it primarily as a cardiovascular and not a respiratory disease as is the common narrative [1, 2, 3]. However, this should, of course, not be construed as a negation of the respiratory nature of infection but merely an observation of the many (deadly) deleterious effects of COVID-19 on the cardiovascular system [4, 5].
It should also be noted that cardiovascular diseases (CVDs) by themselves are a risk factor for mortality in patients with COVID-19 in addition to other conditions like diabetes mellitus, chronic renal failure and respiratory diseases (asthma, pre-existing COPD and pulmonary fibrosis) [6-11]. More specifically, in regard to cardiovascular issues, the most common comorbid conditions in patients with COVID-19 admitted to ICE care as published by an Italian study were: hypertension (49%), CVD (non-specified) (21%) and hypercholesterolaemia (18%) . But how does COVID-19 aggravate existing cardiovascular issues and even causes new ones, like myocardial injury?
The mechanisms of how COVID-19 causes cardiac damage are currently not well-understood and require further enquiry, as do those connected to damage to the vascular system, but it is suspected that it may be caused by severe general inflammation as seen in some patients [13, 14, 15]. Regardless of the exact injurious processes involved, the end results as suffered by patients are well-documented and difficult to prevent and manage, especially in those with specific comorbidities . Individuals with COVID-19, particularly those with the moderate to severe form, are at an increased risk of myocarditis, pericarditis, acute myocardial infarction (AMI), arrhythmia, heart failure (HF), acute pulmonary embolism, cardiac tamponade, cardiogenic shock, Takotsubo cardiomyopathy, right ventricular dysfunction, and thrombosis and probably some yet to be identified [17-30]. Additionally, current research suggests that even asymptomatic/atypical patients might suffer cardiac damage [31, 32].
However, while the acute effects of COVID-19 infection are increasingly well-researched (the formulation of effective treatment modalities is, unfortunately, still lagging) the same cannot be said for the long-term effects—cardiovascular and non-cardiovascular—which are as of now largely unknown and open to speculation. They will undoubtedly be matched or even surpassed by the indirect “cost” of the pandemic (lockdowns).
While the immediate health effects of COVID-19 are familiar to professionals and (despite significant conspiratorial misinformation) laymen alike, those indirectly connected to it are nearly unrecognised outside of professional medical circles, despite the growing number of afflicted individuals. We are talking, of course, about those with symptoms of yet undiagnosed (cardiovascular) issues or chronic conditions that require periodic monitoring and management (as provided by healthcare professionals) who have not been given appropriate attention.
Several studies have already demonstrated a significant reduction in the number of patients admitted to the hospital for myocardial infarction (MI) and stroke— a reduction of between 25 and 40% (for MI) in both Europe and the United States . The reasons for this are numerous and range from fear of contracting COVID-19 in the hospital on the patient’s part to the delayed response of overloaded ambulance and emergency services . The long-term fallout from untreated or late treated cardiovascular issues is, therefore, nearly inevitable unless relevant decision makers take radical steps in ensuring at-risk patients have access to diagnostic and treatment services .
The collateral damage is, however, not limited to cardiac and cerebrovascular issues, but also includes vascular issues. An Italian study on the effect of the pandemic lockdowns on the management and treatment of diabetic foot found a significant increase in the incidence of gangrene and amputations in patients who were admitted for emergency treatment . Lockdown patients were 2-times more likely to have gangrene and suffered 3-times as many amputations than their counterparts who were admitted in the same time period a year earlier when the country was not under lockdown .
The information on the direct and indirect effects of COVID-19 infection on the cardiovascular system presented herein should be sufficient reason for preventive and regular and comprehensive vascular check-ups of at-risk individuals, particularly those suspected of additional, but yet undiagnosed, issues. Nonetheless, this is easier said than done as inefficient workflows, cumbersome bureaucracy and the lack of resources are unlikely to change overnight.
Advancements in telemedicine that enable outpatient and even at-home assessment, to a certain extent (like ABI assessment for PAD), coupled with electronic health records (EHRs) offer a possible solution, at least for some patients. However, some may require more comprehensive examination or treatment and management that traditionally is not available outside healthcare facilities, forcing a radical re-think of how healthcare is provided or judiciously allocating resources so far tied to the treatment of patients with COVID-19.
The acute damaging effects of COVID-19 infection on the cardiovascular system are likely equalled or even surpassed by the indirect degradation of preventive care for specific patient groups and the yet to be researched long-term fallout. At-risk patients should, therefore, be provided with full vascular check-ups to mitigate the risk of future adverse outcomes and an additional burden to the healthcare system.