FDR’s famous words for the great depression may also be relevant for the current scare in cardiac patients of acquiring Covid-19 during hospital visits, which may hinder their proper care. Both the European and US (SCAI) heart societies have been cautioning patients to pay heed to the symptoms and to consider the potential risks of heart attack or stroke, and thereby to report early. A 50-60% decline in emergency admissions is seen by both, and this is mirrored by key Indian Cardiologists also. 50% of the Americans fear more about contacting Covid-19 than experiencing a heart attack, even when the actual threat to life for the heart attack is 10 times more. In the same survey 40% felt that going to the hospital was riskier than going to the hair salon, beach or even a concert. We do know that when it comes to heart attacks, seconds count.
What is the real risk of contracting COVID-19 in a hospital setting with correct protocols in place?
A famous author/surgeon from Mass General Hospital (Boston) reported their experience during the peak epidemic of Covid-19 with correct protocols in place: hand washing, universal masking, social distancing and contact tracing. This resulted in only a rare transmission for even the most vulnerable frontline health workers. Further, no incidence of hospital acquired Covid-19 infection is so far reported for Covid –ve patients, especially when admitted to Covid screened wards.
Let us visit this dilemma further with an evidence-based scientific lens.
Covid is a viral pandemic much like the seasonal flu, with the current world infected numbers as 18 million and deaths at 19.6 lakhs. The case fatality is around 2-3%. But if we were to factor in that asymptomatic persons are 10 times, the real death risk is 2-3/1000 cases. It is spread by droplets, and may now be also (as per WHO) airborne. New York saw large numbers which were flattened by a very proactive Governor using best public health practices. Antibody testing done in a cohort of asymptomatic grocery store visitors in New York was 13-16% then.
India is seeing a large number of new cases and has the 3rd highest Covid cases, though the mortality is low to 2.6% . Antibody testing in Mumbai showed 13.6% asymptomatic cases in developed colonies and 64.6% in the slums.
How do we test for this disease?
Since the virus mainly affect the respiratory system (pneumonia), naso-pharyngeal (R-PCR) done by health workers in PPE is the normal method. Studies have now shown good results with “self- collected swabs” which may allow for less load on health care systems. Antigen testing from saliva, nasal areas are less sensitive (30-40% versus 40-60% for R-PCR). Antibody testing may suggest prior asymptomatic infection and may imply “immunologoical” preparedness.
What are the ways to avoid contacting infection?
Social distancing, wearing masks, frequent hand washing (10-12 times a day for 20/30 seconds with soap and water or 60% alcohol based sanitizers) and avoiding crowded places, especially closed air conditioned areas and prolonged exposure (≥15 minutes) all add up to the risk. Currently goggles or face shields are also recommended by NIH.
What is the risk of death if you have Covid-19?
Most persons with Covid infections in India recover (more than 86%) and mortality is around 2.6%. Elderly (more than 65 yrs but more so above 80 yrs), overweight (obese), hypertensive, diabetics, airway disease like asthma, cancer patients on immunosuppressive drugs, CKD patients etc. are more at risk. India has a younger population and may thus be more immunologically resilient - as may also having had past BCG vaccination (not done in US/Europe) or other “cousin- corona viruses” like common flu, H1N1, SARS, MERS which may have been contacted in the past.
Recent data from US has found a 40% incidence of good “antibody” response despite no covid infection ,based possibly on prior “cousin -corona” infections.
We are welcoming back patients:
Germany, USA are opening up to doing elective procedures which are needed and life -saving. India too is readying to open with significant (upto 80%) decline in the number of patients getting admitted for Covid in Delhi.
But world class safety protocols will continue to be the guiding force. Distancing, masks for all, hand washing and doing covid (R-PCR) test should be mandatory for all invasive procedures. Augmenting safety by having designated areas/floors/buildings for Covid –ve and + ve cases is also appropriate.
Is it safe for cardiac patients to visit OPD’s?
Good public health practices help in a low likelihood of having Covid exposure during a visit. A questionnaire is filled, temperature taken – oximetry, BP and pulse are also recorded. Plastic screens help in distancing and safety. Masks for all (preferably face shields too) and one or no attendants is the norm. Limiting physical examination to essential and time for visit also is to be kept to the minimum. Tele- consultation is catching up and up to 60% of cardiac patients in USA prefer tele- consultation, and physical visits are getting to be less preferred.
Are doing procedures for “Heart Patients” Covid safe now?
Use of good public health practices and mandatory Covid testing pre procedure adds to a Covid safe enviornment. Designated Covid isolation wards too is a step in correct direction. For elective angiography /angioplasty, use of radial route (hand) and next day (early) discharge is the norm to limit the time for in hospital stay.
When patient is unstable, in acute heart attack - doing primary angioplasty, using full PPE level 3 gear for all is mandatory. No deaths have occurred in paramedics/medics who have taken full precautions to don and doff (put and remove) the gears.
What is the benefit of extra dose of vitamins in Covid?
NIH 30 July update negates Vit C, and zinc of any therapeutic value in Covid.
A balanced diet of green vegetables, fruits (for antioxidants) and chicken/ fish/home made cheese as is usually advised for cardiac/diabetic patients is just what the doctor ordered.
Though many nutritionists in India favors turmeric, ginger, flax seeds and probiotics- these have not been advised in the NIH guidelines.
If cardiac patient does develop Covid-19, what is best for him? Hospital Admission? Home Quarantine?
If the patient has good heart functions and has well controlled BP/diabetes and the oximetry is normal (≥94%) with mild symptoms he can be home quarantined with even “home care” plan with surveillance from a close by hospital team.
If underlying condition (BP/Diabetes/Lungs) is not in -range and/or for gross uncontrolled heart failure or CKD (increased urea/creatinine), it is preferred to get admitted.
Use of oxygen if saturation is low or need for ventilator or vasopressors for drop of BP may be needed.
In people on oxygen therapy (not on ventilator) remdesivir, an anti viral drug to shorten duration of illness is indicated as per trials and guidelines. Steroids for those on oxygen or on ventilator have been found to be life saving.
As of 30th July 2020, the National Institute of Health (NIH – Washington, USA) does not recommend the use of plasma despite a 20,000 patient US data.
About 100 vaccines are in developmental phase, but only 3-4 are front runner or potential game changers. But the issue of country of origin, scaling, proof of large phase 3 trials will find this a challenging area to be for world – wide effect in the public health realm.
With ending of lockdown, what is the advice for heart patient?
Follow social distancing, universal masking, hand washing practices and now also, face shields. There may be a need for Covid testing if history of infection is there in a close contact. Some high risk areas like salon, meat packaging areas in US have a mandatory twice a week testing for Covid. Follow practice of less than 10 people, less than 15 min exposure. Avoid talking, singing or laughing loudly. If possible work from home.
When vaccines do arrive – get your Covid shots.
Disclaimer: This Initiative is undertaken in the public interest. The information is only suggestive for patient education and shall not be considered as a substitute for doctor’s advice or recommendations. Please consult your doctor for more information.
For in-depth, objective and more importantly balanced journalism, Click here to subscribe to Outlook Magazine