Gregory M. Weiss, MD

Reflecting on a Year of COVID-19 in Critical Care Cardiology

Slideshows

Dr. Gregory Weiss offers his thoughts on the most clinically impactful studies related to COVID-19 and cardiology released in the past year from his perspective as a critical care cardiologist. 

One Year of COVID-19: A Critical Care Cardiologist's Review

This February marks the 57th consecutive American Heart Month. Instituted in 1964, 9 years after Lyndon B. Johnson suffered his own heart attack, American Heart Month has been promoted by the American Heart Association (AHA) as a way to spread awareness about heart disease which remains the number one killer of both men and women in the United States of America.

It is estimated by the Centers for Disease Control that heart disease kills over 650,000 Americans each year accounting for 1 out of every 4 deaths in our country.

The scope of the problem cannot be overstated. The American Heart Association underscores the challenge that confronts us:

Heart disease kills more people than all forms of cancer combined.

Heart attacks affect more people every year than the population of Dallas, Texas.

83% believe that heart attacks can be prevented but aren’t motivated to do anything.

72% of Americans don’t consider themselves at risk for heart disease.

And 58% put no effort into improving their heart health.

The last three points above clearly demonstrate why an initiative like the annual observance of Heart Month is so important. We as clinicians can seek and find breakthroughs in cardiovascular care every day with no discernable change in the morbidity and mortality being realized when more than half of Americans put no effort into improving their heart health. I suspect that this problem confronts every specialty of medicine. Even with the internet reaching nearly every home, awareness of heart disease remains seriously lacking.

It can be incredibly frustrating as a cardiovascular specialist trying very hard to improve our patients’ quality of life. Even though heart disease has been on the rise since the start of a yearly Heart Month, it is important to understand the benefits of a yearly reminder that resources are out there. Increases in heart disease can be linked to increases in obesity and an aging population. However, getting the word out that heart disease is preventable and treatable can only help us mitigate the enormous cost heart disease places on our lives and pocketbooks.

The main goals of Heart Month are to get people talking about heart disease and heart healthy lifestyles. In addition to prescribing appropriate treatments and lifestyle modifications, we as clinicians can point out online resources and initiatives during Heart Month that can help us teach patients to take a more active role in their cardiovascular care. The National Heart, Lung, and Blood Institute provides a Heart Month Planning Checklist3 for clinicians as a guide to stimulate outreach and suggest available tools that can help us promote a heart healthy community.

This year Go Red day falls on February 5. A particularly important feature of Heart Month is promoting women’s heart health since young women are more likely to die from heart disease than younger men. As a clinician, I welcome every resource I can find to help my patients lead longer healthier lives. This year, Heart Month is even more important.

With the COVID-19 global pandemic we are seeing patients less often with fewer opportunities to promote heart-healthy strategies. Our patients are scared and seem more and more distracted from dealing with their cardiovascular risk factors. People are pent up drinking more alcohol, eating less healthy foods and getting less exercise in some cases. In addition to these issues, COVID-19 puts patients with cardiovascular disease including hypertension, obesity, and coronary artery disease at higher risk for serious infection, hospitalization, and death from COVID-19.4

On a personal note, setting aside a month each year, especially for the last 57 years, lends credence to what we are trying to accomplish. Fighting heart disease is a daunting task, to say the least, and there is a lot at stake. As clinicians today most of us feel more and more isolated. In hospitals, we are seeing fewer elective procedures and significant reductions in office visits. Now more than ever we need to accept all the help we can to reach our patients and continue to provide them with the education and support they need to start and adhere to heart-healthy practices. The American Heart Association and all of its efforts remain a welcome support network for patients and clinicians alike. Shining a light on the problems we face and their solutions can only be a good thing for us as clinicians and for the good people we serve.

https://www.cdc.gov/heartdisease/about.htm

https://www.heart.org/en/around-the-aha/february-marks-56th-consecutive-american-heart-month

https://www.nhlbi.nih.gov/sites/default/files/media/docs/60199-NHLBI-AHM-Planning%20Checklist_508_0.pdf

https://www.nhlbi.nih.gov/health-topics/education-and-awareness/american-heart-month/about

Articles

Dr. Gregory Weiss, a critical care cardiologist, reflects on the importance of American Heart Month and the biggest remaining shortcomings in the fight against cardiovascular disease.

Awareness is the Greatest Medicine in Fight Against Cardiovascular Disease with Gregory Weiss, MD

Over the last year, the global spread of the novel coronavirus COVID-19 has wrought havoc on millions of people and strained the healthcare delivery system. While the vast majority of reports cite respiratory complications as the chief mechanism for morbidity and mortality related to COVID-19 more and more evidence suggests that significant heart damage may be underreported and responsible for significant comorbidity.1 Several small studies looking at troponin I levels in patients admitted with COVID-19 have demonstrated that between 20% and 40% of patients admitted had evidence of cardiac injury.1 Further, patients with evidence of myocardial damage were more likely to die with COVID-19.1

Without a definitive tissue diagnosis, cardiologists often cite myocarditis, or a non-specific cardiac inflammation as a cause for elevated cardiac enzymes in the absence of obstructive coronary anatomy. Compounding an elusive answer to why serologic evidence of heart damage accompanies many COVID-19 cases is the fact that, at autopsy, histological evidence of myocarditis is uncommon.1 Such evidence leads clinicians and researchers to speculate as to what is causing cellular heart damage.

Looking at the pathogenesis of COVID-19 may provide a clue to what is damaging these patient’s hearts. COVID-19 infection and clinical illness is characterized by a dramatic inflammatory response where the body’s immune system, in an effort to combat the coronavirus, damages the lungs by releasing an enormous number of immune mediators. This cytokine “storm” may also be responsible for damaging the heart. Gregg Fonarow, MD, chief of the division of cardiology at the University of California, Los Angeles states, “There is recognition that even some of those COVID-19 patients not hospitalized are experiencing cardiac injury. This raises concerns that there may be individuals who get through the initial infection, but are left with cardiovascular damage and complications."

Fonarow goes on to postulate that late consequences, even in those who have recovered from or never had symptoms of COVID-19 could be a higher risk for heart failure.

 One troubling trend we are seeing is that heart damage seems to be selective. It appears that some patients are affected more than others from a cardiac standpoint

 A recent Journal of the American Medical Association Cardiology issue found that 78% of COVID-19 patients scanned with MRI displayed cardiac involvement with 60% of those going on to have persistent myocardial inflammation.

Important for clinicians is the apparent fact that SARS-CoV-2 (COVID-19) can damage the heart both directly and indirectly. Dr. Eric Topol at Scripps Research Translational Institute in La Jolla, CA describes the close relationship between the COVID-19 spike protein and angiotensin-converting enzyme 2 (ACE2), an enzyme ubiquitous in the human cardiovascular system.

 This evidence may explain how COVID-19 first interacts with heart cells and why people with variable risk factors may be affected differently by the infection. Indirect mechanisms are related to severe lung injury. With severe lung damage, heart failure may follow due to pulmonary vascular complications.

During medical training, it is ingrained in our memory that common things occur most commonly. We know that systemic inflammation is the hallmark of infection with COVID-19. As such it is most likely that the same inflammatory response that damages the lungs may lead to myocardial tissue inflammation or myocarditis in those predisposed to such a complication. This last point is what makes navigating these complications difficult for clinicians and researchers. It is clear that the spectrum of COVID-19 disease presentation is extremely variable. Developing an understanding of why some patients exhibit a completely asymptomatic clinical course while others become mortally ill with multi-organ failure leading to death will no doubt aid in our efforts to describe and treat the cardiac manifestations of COVID-19.

For now, experts advise those recovering from COVID-19 to watch for the following symptoms and to consult their physician or a cardiologist if they experience them

Increasing or extreme shortness of breath with exertion.

Chest pain, swelling of the ankles, heart palpitations or an irregular heartbeat.

Not being able to lie flat without shortness of breath, waking up at night short of breath.

Patients’ should not wait to seek care and we as clinicians must be vigilant for potential cardiac complications in both clinically acute and recovering COVID-19 patients. While hope is on the horizon we have much to learn about how this dreadful disease affects the heart and human body.

Kawakami, R. MD, Sakamoto, A. MD, Kawai, K. MD, et al. Pathological evidence for SARS-CoV-2 as a cause of myocarditis. 

https://www.heart.org/en/news/2020/09/03/what-covid-19-is-doing-to-the-heart-even-after-recovery

Puntmann VO, Carerj ML, Wieters I, et al. Outcomes of Cardiovascular Magnetic Resonance Imaging in Patients Recently Recovered From Coronavirus Disease 2019 (COVID-19). 

 2020;5(11):1265–1273. doi:10.1001/jamacardio.2020.3557

Topol, E. J. COVID-19 can affect the heart. 

. 23 Oct 2020, Vol 370, Issue 6515, pp. 408-409.

In his most recent column, Dr. Gregory Weiss provides an overview of what clinicians have learned related to the effects of COVID-19 on the heart. 

What We Know About COVID-19 and the Heart with Gregory Weiss, MD

So, this happened to me back in December. Working daily as I do here in the trenches of healthcare, I generally learn about my external world via text and email. Like most clinicians I know, during November into December 2020 I watched and listened with great interest as the first COVID-19 vaccines completed trials and were presented to the Food and Drug Administration for emergency use authorization. Unlike many, I had a different idea of what I wanted for my holiday present.

I got the email the day after initial approval for the Pfizer mRNA COVID-19 vaccine. “Dr. Weiss, you have been identified as a first-tier recipient for the SARS-COVID-19 vaccine, please login to your MyChart portal and schedule your first dose.”

Very much like a child opening a present, I immediately logged in assuming that the first available appointment would be months in the future. To my incredible delight, I was able to schedule my first dose the very next day—during the second week of December 2020. I was ecstatic.

I cannot speak for all of my colleagues, but I suspect that many experienced the same reaction I did to being selected to receive the vaccine early. I knew that a heavy weight had been building on my mind and in my heart all year but as with all burdens I got used to it and didn’t notice it as much until this happened. Even before receiving the first vaccine and weeks before it would afford me any kind of protection a haze of worry started to dissipate, worry that I would get sick and become a burden to my family or even worse orphan my children. It was not a blind decision, but one easily made, I couldn’t wait.

I am a scientist and, as such, I generally look into things before I endorse them. I listened to vetted and well-known experts and found out all I could about messenger RNA (mRNA) vaccines. I found out that the trials were not rushed out of thin air but built on the foundations of decades-old research and at least one vaccine designed to combat a previous coronavirus. Understanding how mRNA vectors work, I knew that the vaccine did not enter the nucleus having no interactions with human DNA.

I further recognized the elegance of tricking our own ribosomes to “print” COVID spike protein imposters triggering a response to the appearance of the virus rather than growing real virus in culture which is a time-consuming and potentially problematic method often used in vaccine development. I decided that the development was not rushed but facilitated by a great deal of money and backing from the public and private sectors, something I will revisit at the end of this piece.

On my way to receive my first vaccination, I was not even the least bit apprehensive. As with most healthcare workers, I receive at least one vaccine per year along with tuberculosis skin tests. There is always a chance that one can suffer a serious complication from a new or old vaccine, but the data suggests that the risk is no greater than with any other established vaccine. I was further impressed that the vaccine clinic, set up by my hospital, was staffed by nurses I know and required that all those vaccinated remain in the clinic for fifteen minutes after the vaccine just in case a reaction occurred. Needless to say, they were prepared and did it right. I received my vaccine, waited fifteen minutes, and left with a smile under my mask.

So, what did the vaccine feel like? My first impression was that the physical pain of the actual injection was subjectively worse than say, a flu shot. Initially, I wondered if it was because the vaccine was quite cold having come directly out of refrigeration. Although sore, it was by no means intolerable. Over the next day or so I expected other symptoms, I experienced none. My arm did remain noticeably sore for several days with a level of discomfort comparable to that of a tetanus shot. I knew that in about ten days I would likely have a 50% lower chance of becoming seriously ill if infected by COVID-19. It was a good day.

Twenty-one days later I traveled to the same clinic for my second dose. This time I was expecting to develop some symptoms since my immune system had been primed by the first dose. To my welcome surprise, the second dose was followed by less arm pain than the first and absolutely no symptoms or side-effects. I felt like I had just won the lottery. I felt like things might just be ok, like the corner had been turned. Now ten plus days after my second dose I can expect a 95% reduction in the possibility of developing significant COVID-19 disease.

I have some final thoughts with regards to the vaccine(s). While I experienced almost no symptoms or side-effects, a substantial portion of those I know who also received the Pfizer vaccine reported mild fevers and chills with or without headaches and body aches after the second dose. While reports of Bell’s palsy and other reactions circulate, they are just as likely in patients receiving a placebo. As for the rapidity with which these vaccines were developed, I believe this fact underscores the sometimes dark reality of therapeutic invention while at the same time highlighting what can be accomplished with the right effort.

The reality is that developing medicines and vaccines is expensive. Add to that realization that, in most cases, the companies that develop these lifesaving products do so for profit. Operation Warp Speed withstanding, imagine what drug companies could accomplish if someone else paid for their research and development and then guaranteed that all of their product will be purchased and given away to everyone? I suspect the truth is that if every disease were treated like COVID-19 by the global community, we would have a lot less disease in general. Food for thought and a shot in the arm for all of us.

Dr. Gregory Weiss reflects on his experience receiving the Pfizer COVID-19 vaccine and his thoughts on the ongoing rollout process.

Gregory M. Weiss, MD

Articles

One Year of COVID-19: A Critical Care Cardiologist's Review

Awareness is the Greatest Medicine in Fight Against Cardiovascular Disease with Gregory Weiss, MD

What We Know About COVID-19 and the Heart with Gregory Weiss, MD

My Experience with the COVID-19 Vaccine with Gregory Weiss, MD