Clinical Challenge: What's Coming Post-Pandemic for ASCVD

After more than a year of the coronavirus pandemic, the nation is racking up a cardiovascular debt that will be coming due over the next several years.

Well-documented weight gain -- an average of about 1.5 lbs per month during stay-at-home orders and a median of 15 lbs overall -- will no doubt take its toll. But there have also been missed physicals and chronic disease management appointments where statins and antihypertensives would have been started or uptitrated.

Noel Bairey Merz, MD, director of the Barbra Streisand Women's Heart Center in the Smidt Heart Institute in Los Angeles, pointed to the long-term legacy effect in trials of effective interventions, wherein Kaplan-Meier curves continue to separate for clinical events long after the period of randomization is over and the placebo group largely crosses over to treatment.

"It's like laying down rings on a tree," she said. "If the tree had a year and a half of drought, it will never catch up. For atherosclerotic cardiovascular disease, this will be almost a year and a half of lost management that those people, compared to people who didn't live through a pandemic, would be predicted to have more adverse outcomes."

There were legitimate reasons that people deferred healthcare, she told MedPage Today. But because of it, "we're going to see a tsunami of cardiovascular disease and death."

There's a clear relationship between even modest changes in cardiometabolic risk factors at a population level and subsequent heart attacks, strokes, and other atherosclerotic cardiovascular (CV) events.

Predictions for pandemic-related mortality stem from three streams, Bairey Merz said: "One is the pandemic curve, meaning people that have died and are continuing to die, albeit at a much, much lower rate now, finally. Then there's a second curve that is undetected cancers, surgeries for aortic valves that were not done and were put off, and they're going to come in and it will be too late. Then there's a big tsunami curve coming probably in 2 to 4 years that will be related to our poor ability to risk factor manage cardiometabolic disease."

The year of anxiety and stress has pushed many to focus on their short-term health and safety at the expense of taking care of their heart with diet and exercise, noted Jeffrey Berger, MD, director of the Center for the Prevention of Cardiovascular Disease at NYU Langone Health in New York City.

"I worry that the years we have spent talking about these things, I feel like we have to start at ground zero again," he told MedPage Today. "We have to get people thinking about their intermediate and long-term future and how they can improve their overall health. I think that will be a lot of work."

The psychosocial toll of the pandemic likely did some damage to the heart and blood vessels via inflammation and elevated blood pressure, too, he speculated.

"When we see our patients who we might not have seen for a while, we need to bring up their psychosocial health," said Berger.

On the other hand, one positive might have been the attention the pandemic drew to the lifelong benefit of prevention and control of cardiovascular risk factors, suggested Jennifer Robinson, MD, MPH, director of the Prevention Intervention Center of the University of Iowa College of Public Health in Iowa City.

"Hopefully, seeing the devastating impact of COVID-19 in those with CV risk factors or clinical disease, patient and clinician resistance to effective, safe preventive medications -- such as statins and antihypertensive therapies -- is eroding," she told MedPage Today in an email.

If so, that would help, Berger suggested. "We need to be very aggressive in terms of cardiovascular risk reduction moving forward because of these issues."

Direct damage to the heart and blood vessels hasn't been too common with COVID-19 overall but has been noted more often in severe cases where patients spent time in the ICU. So-called long haulers with persistent symptoms after even a mild-to-moderate brush with SARS-CoV-2 may also need closer attention clinically.

"What are they going to look like in 3 years from now, we don't really know," Bairey Merz said. But if "this activated immune system results in chronic inflammation that doesn't go away, it could result in accelerated atherosclerosis," she noted.

Other autoimmune disorders often carry cardiovascular consequences, leaving the heart and blood vessels at higher risk.

Preventive cardiology won't be spared the continued reckoning with disparities that the past year has highlighted, from racism and sexism to socioeconomics, Bairey Merz noted. "We overturned a lot of rocks, and what we saw wasn't pretty."

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