Is COVID-19 Compelling Us to Bring Out a New Edition of Our Cardiology Textbooks?

The ongoing viral pandemic of 2020 caused by the novel acute respiratory syndrome corona virus 2 (SARS-CoV2) has undeniably unleashed an unprecedented upheaval in the medical world. What began as seemingly isolated cases confined to Wuhan in China, exponentially multiplied and geographically expanded to cause over 11 million cases including nearly 5lakh deaths as on July 6th 2020. ¹ Medical professionals of critical care, pulmonology, and internal medicine were doubtless in the front line, yet its tentacles have not spared affecting practice of any of the medical or surgical specialties. In addition to the increasing morbidity and mortality of patients with the existing cardiac issues, COVID-19 has overnight authored new protocols and doctored novel algorithms to manage clinical entities that we were hitherto unquestionably confident. This is understandably so because these diagnostic and therapeutic strategies evolved after careful scientific scrutiny and large randomized trials adjudicated by hard real-life data. It is probably the first time that a predominant droplet-borne viral infection nowhere in the vicinity of heart has compelled the cardiovascular community to race against time to design strategies to treat heart diseases, to instruct cardiologists on exercising self-care as much as patient care, to caution the otherwise trigger-happy interventionist, and to conduct urgent randomized trials to assess cardiac safety on drugs to treat the corona virus.

The first to surface was questioning the validity of time-tested acute ST elevation in the diagnosis of ST elevation myocardial infarction (STEMI), as patients with this diagnosis were being observed to be devoid of occlusive coronary artery disease (CAD). A study formally recorded no coronary occlusion in 39% of patients diagnosed as acute myocardial infarction (MI) who underwent coronary angiogram. ² Overnight, the differential diagnosis of ST elevation in patients with acute chest pain had to be broadened to include COVID-19, as some of the ECGs of patients presenting with myocarditis or Takatsubo cardiomyopathy were seen masquerading as STEMI. ³ Over the years, the intimidating data favoring PAMI had put this procedure on such a solid foothold that for a patient with STEMI, primary PCI had gone beyond standard of care- or guideline-dictated therapy. In fact, it had become a peer-mandated ethical, and even a medico-legal, necessity. The current zoonotic pandemic has succeeded in initiating a debate on the resurgence of thrombolysis and has facilitated percutaneous intervention (PCI). ⁴ This clinical practice adopted in many centers worldwide notwithstanding the consensus statement by authoritative bodies. ⁵ No doubt this may be a transient phenomenon, but unmistakably a radical alteration in our thought process not even remotely conceivable for a cardiologist standing on a timeline in the beginning of this year. It is indeed difficult time for a specialty habituated by glamorization of interventional procedures, to be practically grounded. Worldwide, moratorium on elective procedures is being advocated and practiced. Probably, we may see more indulgence and support of trials such as ISCHEMIA and COURAGE.^{6, 7} The propensity for the genesis of thrombus in a primarily respiratory infection had an additional etiology for pulmonary thrombo-embolism, and the need for anticoagulation in these patients. ⁸ A heart transplantation program comes with fresh challenges, as donors who are asymptomatic carriers are difficult to identify, and susceptibility and outcomes of recipients are unknown. From cardiac pharmacology, ACE inhibitors have come into controversy. On the one hand, renin-angiotensin system (RAS) inhibition leads to upregulation of ACE2, thus countering respiratory illness and myocarditis in these patients. On the other hand, increase in ACE2 expression may facilitate the access into the host of COVID-19, thus aggravating the clinical picture. ⁹ Currently, no specific recommendations have been issued by societies on initiating or with holding ACE inhibitors. No single pharmacotherapeutic agent in the recent times of recall has witnessed as much controversy as the use of Hydroxychloroquine with or without Azithromycin has been in this clinical situation. A drug so casually used for decades by those at the bottom of medical hierarchy in India for febrile illnesses and long-term administration by rheumatologists is seeing confused minds and trembling hands of specialists while prescribing this agent for COVID-19. A large data published in Lancet attempted to resolve this issue, but it is difficult to believe this is an end to the “to be or not to be” controversy. ¹⁰ The large lists of unfortunate COVID victims published on the front page of the New York Times and elsewhere in the globe are not devoid of names of medical specialists, including cardiologists. There is a huge understandable concern to use personal protection equipment (PPE), but to what extent, how long, and on who all is the dilemma. ¹¹ The line between cautious safety and over zealousness is becoming thinner. The cardiology community may show its prudence in not expecting a conquest over such alien unlike adversaries in the past, but in designing practical and viable strategies to go around them.