Analysis

COVID-19 cardiac complications: counting the long-term cost

The virus has been linked to heart damage, but has also disrupted care across the specialty

The virus has been linked to heart damage, but has also disrupted care for those with existing conditions

  • A growing body of evidence suggests that COVID-19 can cause serious and lasting damage to the heart
  • There are concerns that people who have experienced heart attack or other cardiac conditions have avoided hospitals because of COVID-19 and not getting the support they need
  • How cardiac services have adapted and reorganised to work within the restrictions brought about by the pandemic

There is growing evidence that COVID-19 can lead to dangerous and lasting heart damage.

This in itself is not surprising – severe flu can also cause heart-related problems – but

The virus has been linked to heart damage, but has also disrupted care for those with existing conditions

  • A growing body of evidence suggests that COVID-19 can cause serious and lasting damage to the heart
  • There are concerns that people who have experienced heart attack or other cardiac conditions have avoided hospitals because of COVID-19 and not getting the support they need
  • How cardiac services have adapted and reorganised to work within the restrictions brought about by the pandemic
Picture: iStock

There is growing evidence that COVID-19 can lead to dangerous and lasting heart damage.

This in itself is not surprising – severe flu can also cause heart-related problems – but with the UK battling the second wave and the vaccine roll-out still it its early stages, how concerned should nurses be? And what can they do to help?

Growing body of evidence links COVID-19 and heart-related problems

There has been a steady trickle of news stories about the risk to the heart from COVID-19 infection since the start of the pandemic.

1 in 5

people hospitalised with COVID-19 suffer heart damage

Source: Diseases

The first reports came out of Wuhan in China at the start of the outbreak and since then a growing body of evidence has been emerging that suggests a variety of cardiac-related complications.

A meta-analysis of 27 studies by teams in the US and Thailand has suggested around one in five COVID-19 patients who are admitted to hospital suffer some sort of heart damage, with those with pre-existing comorbidities at particularly high risk of further injury.

For a significant number the damage is likely to have a major impact on their survival and recovery.

COVID-19 made my heart problems worse

Mark Wilkinson is just one of many people who has suffered cardiac-related complications following a COVID-19 infection.

The 62-year-old from Leicester was already struggling with heart failure related to a leaky aortic heart valve, which was diagnosed in 2015. But Mr Wilkinson still led an active life, including going on long hill walks, until he caught COVID-19 last year.

When he first became ill, he says he ‘had a high temperature, relentless thirst and episodes of uncontrollable shaking. I went from being extremely hot to feeling freezing cold’.

‘Each day was like being on a rollercoaster but in the dark. I never knew what was going to happen the next day or how I’d feel.’

After nine days of feeling unwell, he was admitted to hospital and treated with intravenous fluids, antibiotics and paracetamol for the COVID-19 infection and the pneumonia that had developed as a result.

For a fortnight after he got home, he felt exhausted – and then he developed new symptoms.

‘My heart was beating really fast and irregularly and I was sweating profusely,’ he says. ‘I felt more ill this time than I did before.’

He went back to hospital, where he was diagnosed with pneumonia again and atrial fibrillation, or irregular heartbeat.

He responded to treatment, but Mr Wilkinson’s energy levels took around six months to get back to normal.

‘Each day was like being on a rollercoaster but in the dark,’ he says. ‘I never knew what was going to happen the next day or how I’d feel. That made it feel particularly difficult.’

Heart issues that can affect those infected with COVID-19

A British Heart Foundation (BHF)-funded study published in the European Heart Journal found around half of more than 1,200 patients who received a heart scan while in hospital due to COVID-19 showed abnormalities in their heart function, with around one in seven showing severe problems that were likely to have a lasting legacy.

Problems have also been found in the hearts of people who have recovered from COVID-19, including those who did not need hospital treatment.

Research published in the Journal of the American Medical Association Cardiology found that patients who had been diagnosed with COVID-19 had higher levels of troponin in their blood – an indication of heart damage. They also had a slightly worse measure in their heart’s ability to pump blood, known as ejection fraction.

More than three quarters had an ‘abnormal finding’ on their cardiac MRI, including changes to the size and function of the heart chambers.

Many COVID-19 patients who are hospitalised also develop heart problems Picture: iStock

Reasons for heart complications in COVID-19 patients is still unclear

Silapiya Smith, a heart failure nurse based in the south east and a member of the British Society for Heart Failure (BSH) nurse forum, says specialist nurses are already seeing the impact of COVID-19 infection, but the reasons for the heart-related problems are still not clear.

‘The evidence is emerging,’ he says. ‘What is understood is the infection triggers a high inflammatory response within the body, causing a number of cardiovascular effects, one of which is myocarditis causing heart failure.’

BHF senior cardiac nurse Lucy Martin agrees. ‘There is still a lot we don’t know. The research done so far has looked at quite small groups of people.

‘We know COVID-19, in some patients, causes an inflammatory response and blood clotting that will increase the risk of things like heart attacks and strokes.

‘We also need to know more about why people with heart disease are among the most at risk to suffer serious complications from COVID-19.’

A partnership set up to investigate heart risk

Ms Martin says the important thing now will be long-term follow-up of patients, which is happening thanks to a partnership between the BHF and National Institute for Health Research.

There are seven separate studies looking at everything from the consequences for the heart of infection to the wider implications of the pandemic on cardiovascular health.

33%

fewer patients were seen in cardiac rehabilitation programmes in July 2020 than in February that year

Source: BHF

In fact, the wider implications are an important factor in the increased heart risk the population faces as a result of COVID-19, says Ms Martin.

‘There was a 50% drop in people attending emergency departments with heart attacks during lockdown,’ she says. ‘We know people did not suddenly stop having heart attacks, so we fear many stayed away and are not getting the support they need.’

She also points to a drop in the numbers taking part in cardiac rehabilitation, which fell by a third between February and July, while around 15,000 patients had heart-related procedures such as heart bypass surgery postponed.

Spotting the signs of heart failure

British Society for Heart Failure nurse forum chair Carys Barton says heart failure is often diagnosed late when patients are admitted to hospital, but that evidence shows people are often having symptoms many months before admission.

‘We want to do more to identify symptoms of heart failure early and stop people being admitted to hospital,’ she explains.

‘Nurses – district nurses, practice nurses and those working in the community – are in an excellent position to spot the signs of heart failure, such as breathlessness and swollen ankles for example.’

She says the most important step to take is to arrange for simple blood tests which measures the peptide NT-proBNP.

Testing blood for a cardiac marker for acute or chronic heart failure should be the first step
Picture: iStock

‘If it is elevated the patient will be put on either a two-week or six-week referral to see a specialist,’ Ms Barton says. ‘If it is not elevated, you know you can rule out heart failure and explore what else it might be.’

Portsmouth Hospitals NHS Trust heart failure nurse specialist Mark Green says the blood test is vital but it is also important to spot the signs of deterioration in patients who have already been diagnosed with heart failure.

‘Lots of nurses will come into contact with heart failure patients – district nurses, community matrons, practice nurses and palliative care services.

‘We do need to act and encourage patients to seek help. Our patients are vulnerable; COVID-19 and heart failure is a really bad combination’

Mark Green, heart failure nurse specialist, Portsmouth Hospitals NHS Trust

‘It would be helpful if they were confident in spotting the signs of deterioration so that advice or treatment can be sought quickly before the patient gets to the stage where they may need to be admitted.

‘One of the red flags I have used on telephone consultations is being aware about rapid weight gain with the associated shortness of breath. When a patient is putting on two, three, four pounds every day that is a sign of fluid retention. It is not going to be diet, but they can hide that in their legs or abdomen.

‘The other red flag is changes in sleeping – if the patient is using lots of extra pillows or sleeping in a chair to ease their breathing while they sleep that is a sign of deterioration.’

He says patients with these signs need to be referred on to their GP, but he also says in many areas there are lead cardiac and heart failure nurses that can be contacted for advice.

‘We do need to act and encourage patients to seek help. Our patients are vulnerable; COVID-19 and heart failure is a really bad combination.’

Effects of the pandemic on mortality connected to heart problems

There is already evidence all this has taken its toll on mortality.

The numbers dying from heart problems in England between March and October were 7% higher than would have been expected, an analysis by BHF on behalf of the Press Association found.

During this period there were 73,800 cases where heart or circulatory disease was named as the underlying cause of death – 4,785 higher than expected.

7%

increase in heart-related deaths was recorded between March and October 2020

Source: BHF

BSH nurse forum chair Carys Barton says these trends are worrying and warns the full impact of that will take some time to be fully realised.

‘Our concern is that we will see people coming forward in the coming months in a worse condition because they delayed seeking help,’ she says. ‘These people are potentially at significant risk of long-term heart damage and even premature death.’

Changes to services during the pandemic

Ms Barton says that, like other areas of healthcare, cardiac services have had to be overhauled during the pandemic.

This has included an increased use of ‘cold sites’ away from hospitals, in community clinics and local health centres to see patients face-to-face, as well as carrying out more home visits.

Remote consultation via the phone or through digital technologies has also been undertaken.

‘It has probably helped to push innovation faster than it would have otherwise. We have also collaborated more with primary care teams,’ she says.

‘We’ve asked GP surgeries and community teams to do blood tests, physical exams and blood pressure monitoring when they have been seeing patients.

‘It is good for the patients – it means fewer appointments and, of course, reduced contact.’

How cardiac services have adapted

Heart services across the NHS have had to be revamped during the pandemic.

At the North Devon NHS Foundation Trust this has included a move to a one-stop shop approach so that patients who come in for echocardiograms and electrocardiograms receive their assessment from a specialist nurse or cardiologist on the same day.

For follow-up appointments, home visits and clinics run in community health centres have also been used much more.

Meanwhile digital and phone consultations have become commonplace for routine check-ups with the Attend Anywhere platform being used, although many older patients have reported preferring the phone.

Remote consultations are being used more as a result of the pandemic Picture: iStock

Remote cardiac rehab programmes

Rehab programmes are also being done remotely. The trust has used Heart Manual, a remote rehab service for patients who have had a heart attack, while the team’s exercise specialist has run bespoke virtual appointments for patients.

Heart failure patients have benefited from a rehab service that was launched by coincidence in February when the pandemic hit.

The service, known as Reach-HF, is delivered at home through a 12-week programme, which is customised by the individual, their carers and the specially-trained cardiac nurses. The idea is to create a ‘self-help manual’ to help them manage their condition.

North Devon lead nurse for cardiac services Poppy Brooks says: ‘In many ways, the pandemic has forced our hand with innovation and made it happen more quickly than it would have otherwise. When the pandemic ends, I am sure many of the practices we have used will continue – we will want to offer patients choice.’

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