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Melanie Cole: This is the Northwestern Medicine Podcast on COVID-19 dated May 1st, 2020. Welcome to Better Edge a Northwestern Medicine Podcast for physicians. I'm Melanie Cole and today we're discussing COVID-19 in cardiology. Joining me is DR. Clyde Yancy. He's the Chief in the Division of Cardiology and Associate Director of the Bloom Cardiovascular Institute and Vice Dean of Diversity and Inclusion at Northwestern Medicine. Dr. Yancy, as our experience with COVID-19 increases. We're beginning to learn more about the potential complications and outcomes. What can you tell us about COVID-19 and heart disease?

Dr. Yancy: First, we should know that COVID-19 is the illness this caused by the novel Coronavirus. That illness is predominantly a respiratory illness, but we've learned that there are cardiac consequences. Those cardiac consequences can be fatal and we know the patient population in whom those cardiac consequences are most likely to occur. It is the older patient, possibly the male patient, the patient with underlying hypertension or diabetes and especially the patient with known cardiovascular diseases, especially coronary disease and heart failure.

Host: Why do we think patients with known cardiovascular disease are at an increased risk?

Dr. Yancy: What we're learning so far and what has been replicated in multiple datasets now, is that clearly the patient with preexisting cardiovascular disease is at risk for the worst outcomes, intubation, kidney failure, thrombosis and death. That as the COVID-19 disease progresses, the most worrisome stage is when there is an overactive immune system response. You may hear more and more conversation, more and more dialogue about a cytokine storm. When that occurs, there is this overwhelming flow of interleukins and other factors that drive inflammation and particularly with an underlying less than ideal cardiovascular system. That storm of interleukins with vasodilatation and hypotension can be overbearing.

Host: We've heard so much about ACE inhibitors and ARB's in this setting. What's the backstory on these questions and what guidance can you offer your peer physicians?

Dr. Yancy: The science is elegant, but the short version is that there is a component of the renin angiotensin aldosterone system known as ACE2. When ACE2 is present, it facilitates the entry of the novel Coronavirus into epithelial cells, particularly into pulmonary cells. That appears be the beginning of the cascade that leads to respiratory distress, and so there have been questions to say, well, don't those drugs, ACE inhibitors and ARBs elevate ACE2? We don't know that for a fact. The signals are not consistent and the degree to which ACE2 is modulated by those compounds is not well understood. We don't have any evidence at all from any clinical series yet published that the presence of the ACE inhibitor or ARB will make the disease worse or conversely, we'll protect from the consequences of the disease, but we do know this for the appropriate indications for which the ACE inhibitor or the ARB or prescribed abrupt cessation can lead to further decompensation of the cardiovascular system, which is the last thing you want to have happen during a COVID-19 infection.

Host: With the major focus on COVID-19 it seems as if our usual acute coronary and heart failure patients have disappeared. What's going on? Do you have any thoughts about that?

Dr. Yancy: There's been an odd observation that many have had empirically or anecdotally, but we're waiting to see the data come together. It looks like our usual acute care patients are now with us. The acute cornea syndromes, the acute imas, even the heart filled with exacerbations. What's happening, we don't know if people are staying home because of fear coming to the ED, but do realize that many people who are following a stay at home order are actually following a fairly sedentary lifestyle, so their physical activity may be below the level that would provoke cardiovascular systems. We've checked on them recurrently to understand how are they doing if someone's having an issue. We've tried to steer them towards less acute care facilities for low level testing and engagement just to be certain they're okay. Don't believe that the patient's on there, they're there, but maybe what needs to happen is a different kind of engagement and inventory, if you will, so that when the all clear happens and we hope that soon we can bring in those patients that need to come in soonest and then triaged from that point forward.

Host: Dr. Yancy, the issue of race and COVID-19 has emerged and many of our listeners practice in racially diverse areas. What should we know about this?

Dr. Yancy: As we've been struggling with the COVID-19 crisis, a new challenges emerge. One that is particularly important to me. It appears as if those that are African American or experiencing a disproportionate burden of disease, including a higher likelihood of death. We know from very well curated information that the infection rate is three times higher and the death rate is six times higher in blacks compared to whites. Same trends are emerging for Hispanics. Why is that the case? Part of it may be because of things like hypertension and diabetes and obesity, but part of it may be because of where people live and how they live. We've heard terms, social determinants of health, built environment, vulnerable populations, and some of even argued that all of that's rhetoric. Actually it's not rhetoric. What we're learning is that when there's limited access to healthy foods, when the location where someone lives is a population dense area or an area that has a higher crime rate, those things have a bearing on health.

Independent of anything else that we can measure and so that creates a vulnerability. It's not just for COVID-19 but frankly for cardiovascular diseases, cancers and many other things. There are investigators looking at the genetics of the Coronavirus and we may down the road find that there may be some individuals where the risk is particularly high because of a genetic susceptibility. But today we have no evidence that genes play a role here and we think that it's life and living circumstances and the preexisting conditions that drive most of the exposure to racial groups. So we just have to appreciate the part of what COVID-19 has done is unmasked a pretty deep chasm in our communities between those that are healthy and those that are not. And this is something that will live on beyond COVID-19.

Host: We know what you're going to say, but what's the best advice for prevention, Dr. Yancy?

Dr. Yancy: There's a lot we know, but there's more that we don't know, and particularly we don't yet know of an effective therapy for COVID-19. One is social distancing, maybe even physical isolation. We need to respect the risks, understand the vulnerability and follow through on not just social distancing, but particularly for our older citizens. Physical isolation. It means wearing a mask in public. Bear in mind, with everything that I'm emphasizing about prevention, there's one thing we can't allow to happen. Social distancing is good. Physical isolation is better, but social isolation is not good. This is a time to check on people. We can't allow depression and isolation to lead to even worse consequences of this infection. So social distancing, yes, physical isolation, a hard yes, but social isolation. No. Stay engaged, if necessary, increase your network.

Host: Is there any good news, particularly new clinical trials that may provide important new data?

Dr. Yancy: This has been a wretched experience, but we're discovering in an experiment we never intended to host. The public health measures can actually make a difference. We have effectively flattened this curve by the behaviors that many, many people have done. Not by drug, not by vaccine, but by behaviors. That's good news. Second, we have incited a kind of research enterprise that we've not seen before. The work that is happening right now to stand up and test new vaccines, to stand up and test new therapies has been extraordinary. There is a degree of scientific collaboration that is unprecedented. Every lab, every clinical trial unit, everybody's putting all their chips to the table and say, here, let me do my part. Let's make a difference here. And then finally, we recognize that the importance of emergency preparedness, it's very easy to be lulled into these are the good days everything's working well. But the good news out of a crisis is that we now understand that being prepared is an ideal strategy. No matter what we face next, and being adept at emergency preparedness will help us so much more in the future. So yeah, there is good news, and if we act on the news and don't let it become a distant memory, this burden that we're experiencing now hopefully will not be replicated.

Host: Thank you so much, Dr. Yancy. It's such important information at this time, and that concludes this episode of Better Edge, a Northwestern Medicine Podcast for Physicians. To refer your patient or for more information on COVID-19 please visit our website at nm.org to get connected with one of our providers. Please remember to subscribe, rate, and review this podcast and all the other Northwestern Medicine podcasts. Please share these shows on your social channels because this is such important information and we're all learning from the experts at Northwestern Medicine together. I'm Melanie Cole.