Cardiovascular Sequelae of COVID-19 in Adults: 2022 ACC Expert Consensus Decision Pathway

Welcome to a Heart To Heart Nurses brought, to you by the Preventive Cardiovascular Nurses Association, PCNA's mission is to promote nurses as leaders in cardiovascular disease prevention and management.

Geralyn:
We are so excited this morning to have Dr. Ty Gluckman with us to discuss something that's very recent and very cutting edge and is going to be of great importance to the clinical staff at your facility and beyond.

So, Dr. Gluckman, why don't you give us a brief overview of who you are and why you're here.

Dr. Gluckman:
It's a pleasure to be with you. I am a clinical cardiologist within the Providence health system up in Portland, Oregon. I serve as medical director of the center for cardiovascular analytics research and data science. I still practice clinically, but I also do research. And I would say most importantly about why I'm with you is I had the good fortune of serving as the co-chair for recent expert consensus decision pathway, a guidance document issued by the American college of cardiology. That's focused on cardiovascular sequelae related to COVID-19 in adults.

And more specifically we focus on myocardia. We focus on post-acute sequelae of SARS-COV-2 infection, otherwise known as long COVID and then returned to play, helping people understand what they should be doing as it relates to evaluating people who may be athletes or going back to being more.

Geralyn: I am really excited that we're able to talk about this. So recently after its publication, I know it's
available at the ACC.org website under the guidelines area. And it's near the top. If it's not the very first
thing that you see when you pull that up. So we'll put a link in our resources page so that people are able to access it in its fullness. But what are some key takeaways?

If you put yourself in the shoes of a clinical. Individual who is seeing, seeing patients that have maybe the risk of having these things or definitely is showing some symptoms. I know part of the document talks about those that are asymptomatic, but still are at risk. What are maybe what's the top takeaway that you would start with as a clinician seeing patients?

Dr. Gluckman: I would dare say. SARS-COV-2 infection in the pandemic of COVID-19 has affected us all in so many different ways. From a clinician medical side of things. We are now faced with a very large number of people who have had the infection in the past, or have it now. And the challenge is that the science to a large degree hasn't caught up. The reality that we're seeing these patients. And so we designed this document to really be a practical way of approaching the evaluation and management, where we don't have all the answers, but we're getting experts opinion about, for a patient that you're seeing who has chest discomfort, shortness of breath, other cardiovascular symptoms in association with temporarily their actual infection or thereafter.

What should I be thinking about how do I go about evaluating that individual? What should I be doing to manage that individual? And so we met this to be a very practical document. We recognize that this will evolve over time as the science accrues, but we felt there was a very strong need to arm people with some tools to sometimes tell them what to do, but to also be clear in telling them what they don't need to do in terms of testing.

And for many of us going back now a couple of years, We were learning as we were going use the expression, we're flying the plane as we're building it, but we're still at a point where we have a lot that we don't know.

Geralyn: So you talked about the things that people should consider in terms of not doing what are some common types of activities that you see in the clinic in terms of testing that is occurring, that at this point may not be necessary. As we're talking about individualized care. And we know that you look at each patient as an individual and the circumstances in which they are living in which they are being schooled in the environment in which they live, which also might have some impacts on this. But what are some things that may be clini
cians do not have to worry quite so much about that may be, might be front of mind.

Dr. Gluckman: Previously, it's a phenomenal question. And we're all going to increasingly see people who have had, or are having COVID and we're seeing people who've had recurrent infections overall. I would also say. COVID has affected nearly every organ or body system that exists. And so this document was written with an eye towards evaluating people who have cardiovascular symptoms that may or may not be related to the infection as it relates to that for individuals that are a symptom of.

Really not much in the way of testing is required at all from a cardiovascular standpoint, for a, what if scenario or what if their heart was affected either from a prior infection or currently, if they're not having ongoing
symptoms, there really isn't much in the way of testing that is required. The challenge that we had was early on with the benefits that we havein cardiovascular medicine of unbelievable technology. We had experts who are a part of this. Who we're not only getting electrocardiograms and echocardiograms on these patients, but cardiac MRIs, pet scans. And we learned a lot in the process. I'm not sure we fully understand what everything was reflective of. The biggest area that accelerated this was the issue of athletes and collegiate and professional athletes.

So these individuals will often undergo exhaustive testing that most of us don't undergo, even if they're asymptomatic. And in the midst of the pandemic, many of these individuals had mandated what was called triad testing. They would get a cardiac proponent, an electrocardiogram and an echocardiogram, but in many cases they were getting cardiac MRIs and we found abnormal.

But these didn't often match to people who had clinical manifestations of myocarditis. So I think the simplest takeaways are for asymptomatic individuals from a cardiovascular standpoint, not much in the way of anything needs to be done, recognizing that someone who's asymptomatic today could develop or manifest cardiovascular symptoms, weeks or months down the road, simply being asymptomatic upfront doesn't mean you won't develop symptoms down.

Uh, the other end of the spectrum for individuals who present with signs or symptoms suggesting cardiovascular involvement in someone who's had a recent infection or is currently infected those individuals warrant, further evaluation. And the questions at hand are, does the person sitting in front of me have mild carditis or other forms of cardiac or myocardial involvement.

Um, and what are the implications of that? If they do. Our document addresses this both from the standpoint of the infection itself, SARS-COV-2 infection, but also there's been a lot of discussion, although a rare entity of myocarditus associated with the COVID-19 MRR and a vaccine. And then we also spent a lot of time talking about long COVID and we recognize that there are a range of symptoms.

Some not even related to the cardiovascular system. Some perhaps relate to the cardiovascular system that individuals with long COVID may have. How do we help clinicians be armed with tools to better evaluate and manage those patients.

Geralyn: That is all accepted, ugh, applicable information to clinicians in a variety of settings. Do you have any other clinical takeaways that you think our audience primarily cardiovascular nurses would be interested in hearing from you?

Dr. Gluckman: I would say I am a huge fan of team-based care, and I want to reinforce this very strongly to say that it not only requires team-based care within the cardiovascular space. But the recognition is many of these individuals are going to present to their primary care clinicians. Initially some of these patients may
have been hospitalized and obviously see those appropriate clinicians in the hospital, but we're all working as a team. And what I mean by that is we have seen large numbers of COVID clinics that have opened up across the United States.

And for that matter worldwide, These are often multidisciplinary groups that involve primary care clinicians, cardiologists, pulmonologists, gastroenterologists, infectious disease, experts, psychologists, and psychiatrists.
We're all trying to be neurologists. We're all trying to figure these issues out. So for individuals that are listening to this today, recognize you're part of a very large team, but also you should be armed and feel comfortable that if someone who's presenting, whether they were asymptomatic or highly symptomatic in the past, and they're now having symptoms, what in fact may be going on? I will just mention one other thing. We, in this, we presented a framework in this document to think about for long COVID patients who are presenting with symptoms that make one, think about the cardiovascular system chest.

Shortness of breath, palpitations, exertional fatigue. Those don't automatically mean that you have cardiovascular disease. We actually present essentially a construct that introduces two new terms. One is Pasch CVD. Post-acute sequelae of SARS-COV-2 infection, cardiovascular disease. Only to point out the fact t
hat it may be true, true and related are true. True and unrelated people with preexisting heart failure may have
had their heart failure worsened by the infant. We know that infections predating SARS-COV-2, that viral infections can uncover previously unrecognized cardiovascular diseases. And for all patients who present with
symptoms or signs, where you're thinking about heart failure and arrhythmia, ischemic, heart disease, do the standard evaluation that would be appropriate for evaluating. And treat them appropriately. If you identify atrial fibrillation, heart failure, coronary disease, we introduce a separate term called Pasch CVS for cardiovascular syndrome. And this is very frustrating for both clinicians members of the clinical team and patients alike because often they may present with tachycardia, exertional, fatigue, chest discomfort, shortness of breath, and the standard evaluation. Doesn't reveal a specific cardiac etiology, and yet they're still per
sisting and having symptoms. And we have seen some of the most healthy, vibrant individuals, very physically fit who have been very much effected during the era of long COVID and incapacitated by a lot of things going on for these individuals, recognizing that the pathophysiology, the drivers of this maybe new.

And I'll be honest. I'm not sure we exactly know what may be the driver or drivers of it. We actually present it from the standpoint of the clinical presentation to phenotype. So if you present with tachycardia, how should you think in someone who's had a basic evaluation, what may be the re extended evaluation and how do you best manage it?

Same thing for chest discomfort, same thing for shortness of breath. And so this is meant to recognize that, and I think it's a really important topic. You're going to see patients who are exquisitely frustrated by the fact that they feel like people are not listening to them. They've had basic evaluations that have been unrevealing.
It makes us as clinicians sometimes frustrated because we don't know where to go next, but I can assure you patients and their loved ones, their support system gets very frustrated when you say. I was very, very functional. I had none of these symptoms. I have an infection and now I'm left with very debilitating, mild, moderate, or severe debilitation. Uh, we recognize it's there. And I think even just affirming and
recognizing a patient's symptoms and then being able to figure out where do I go next? Or how do I find a friend and get some help in somebody?

Geralyn: We have had such a great conversation thus far, Dr.Gluckman. I am so excited that you're here.
We'll be right back with more information on this recent ACC expert consensus document. And we'll look for you in just a moment. We are back with Ty Gluckman, who is here talking about the 2022 ACC expert consensus decision pathway on cardiovascular sequelae of COVID-19 and adults. That's a mouthful. Uh, Dr.
so apologies to the folks that put it together and worked so hard toget that all together. What can you tell us about clinicians who might be interested in sharing how information, how data is gathered for decision
pathways like this, and particularly for COVID there's a lot that we don't know. It seems like we've been in COVID for decades, but the time span is really short. And I think sometimes it's hard for us to realize that we have done so much in such little time, but there's so much more to learn. 

Dr. Gluckman: You said it better than most have. Um, it is truly striking that in a period of roughly two years, how far we've come. Let alone the development of multiple vaccines that work different ways to help provide protection to all individuals, uh, at least adult individuals down to now age five, as of the date of this recording, hopefully younger in the future, uh, to provide protection, but I will also say it has been truly amazing
within the broader medical community.

None of us have ever seen anything like this in our lifetime, you go back to the Spanish flu. There are really a paucity of individuals who can relate anything about that era. So it is cardiologists, neurologists,
gastroenterologists, psychiatrists, all exploring this area. I will say specifically in the cardiovascular arena.
There's a lot we still don't know. But we have begun to better understand the prevalence and the incidence of some of these conditions based upon registries or other data collection systems that have been set up. So, as an
example, the government has set up the vaccine adverse event reporting system, a repository to inventory when someone has side effects, adverse events related to the vaccine. To where we've learned the most about the potential for the MRI and vaccines to cause myocarditis. And the rates are very low, tend to skew
disproportionately to younger individuals and male individuals. But even at that with rates that are somewhere between about 50 to a hundred cases per million, so still very uncommon scenarios. Overall, the challenge with that there's likely under-reporting when you expect somebody to log into a system. And so we've seen
some real world data sets that have been able to translate into real-world evidence and health systems, including my own early on, we actually published some of the early data looking at,Uh, a decrement in people presenting to hospitals with heart attacks and what were the risks attendant with that overall? And so it was, I think it's been an amazing time under very unfortunate circumstances to be able to come together. And we've seen partnerships develop. We have seen our professional societies stand up registries. I've been fortunate to be a part of the American Heart Association's COVID-19 cardiovascular disease registry. Health inequities, disparities and care, but also what's actually happening. Overall, the sports medicine community and specifically sports cardiology has stood up a tremendous amount, both in terms of initial case series, not
withstanding the limitations of those, but we've seen three large registries that have been published, looking at collegiate or professional athletes, allowing us to better understand over two years, what is the rate in which clinical myocarditis.

What are the different myocardial abnormalities that may exist by an electrocardiogram, an echocardiogram ultrasound of the heart or a cardiac MRI? So there's no question we've learned a lot, still a lot more to learn and maybe an opportunity to accelerate areas in which randomized trials have been problematic. Like the field of myocarditis. This is an opportunity to really be able to do our gold standard type of research. The last piece and I did reserve it purposely last is past or long COVID is a really challenging issue. It's estimated
that between 10 to 30% of infected individuals are developing some manifestation of long COVID in the U S defined as either persistence or emergence development of new signs or symptoms that are tracked back least believed to be temporally related to SARS-COV-2 infection four weeks or out beyond infection. Uh, the Europeans have looked at longer time horizon for 12 weeks, but the U S is using four weeks. There's so
much that we don't know, but we recognize that large numbers of individuals are affected and the clinical impact is going to be substantial. The societal financial, uh, can people work, are they incapacitated? All of these have huge effects. So the federal government and the NIH recently announced a very low. Funded study. And there are others coming called the recover trial or initiative that is seeking to essentially phenotype.
They are doing other laboratory and genetic testing and doing much more than that, but help us understand what exactly is going on while that may seem like a huge investment for hopefully, fingers crossed, a pandemic that's waning.

We're still seeing variants now at a Europe, the BA dot two variant and fingers crossed. We don't see large impacts in the United States. We also believe that there will likely be additional variants and disappointingly, but being very pragmatic about it. We're going to see other viral infections. And hopefully I don't see it, but I think I'm being unrealistic.

There will likely be additional pandemics in my lifetime, certainly in my children's lifetime. And so we need to be better prepared. And I think all of this is reinforcing the need for investment in public health strategies, both for caring for individuals, but also learning from boots on the ground what's going
on.

So we can course correct more rapidly than we have in the past, but also preparing us for new therapeutics, new ways to approach evaluating and managing. With viral or other types of infectious etiologies in the future.

Geralyn: Again, you've given us a great deal of information for us to consider and think about how it's going to apply in practice. I'm wondering if you have any suggested resources that you could point clinicians towards if they are interested in enrolling patients in these trials, but perhaps, or. If they just have questions about what the research is saying. Are there some key places that you would go to that you would point other clinicians towards?

Dr. Gluckman:It's a great question. And I would say in the midst of the pandemic, but even today and more, if it was acute care centric early into the pandemic now shifting not exclusively, but to more ambulatory, there are trials going on at many Haas. Uh, large, medium and small across the United States. So if you have patients, there are questions that are being asked as there always are with a pandemic.

See if your patient can be enrolled in a clinical trial, and if you don't have it at your hospital, do you have it in your local geographic locale? I guess that's comment number one. Comment number two is, um, the CDC is a great resource. Uh, it, uh, is very, they're very timely in their updating of information. I turned to quite regularly, the NIH treatment guidelines. So if you type in any web browser, uh, COVID-19 NIH guidelines, you will see it and it's broken down on an evaluation and treatment perspective. Overall, it's a really great resource. I would encourage people to go. And then our document, we'll make sure that there's a link available. It includes a lot of information, but importantly, their references, and to go back to some of it, where did the data come from that suggested that there's cardiac MRI involvement. It can point you to some of the data. One of
the challenging issues that may be putting it, mildly that we had with putting out this document is we had to put pencils down at one point and actually publish it. But the challenge was new science was coming. I will say at least weekly and sometimes daily and a challenge related. This is how do you produce timely information? That's useful, but recognize that the science is evolving. If not weekly, definitely monthly and quarterly. I think it prompts the recognition that we're going to have to come up with updates to this document as the science bears out overall. But there's a plethora of resources that are out there. Those are just a few ones too. 

Geralyn: Those are exceptional places to look for this kind of information that as you've said is changing at least weekly, if not daily, if not hourly. And our practitioners definitely know that. Trying to put that into practice can be a challenge, if not a challenge and a half. Is there anything else that you would like to add that I've neglected to ask you about?

Dr. Gluckman: You've been a pleasure to chat with. I would say, uh, be patient during this period of time. It's hard to be patient in the middle. All of the impacts that the pandemic has had for the last couple of years. I do really think unlike ever time in my clinical lifetime, we've seen science shed, such a light on something that was brand new to the world in a matter of two years. And so I think our knowledge will grow. I think we've learned a lot about. How do we get data out there quickly? And even the challenge of do we have to wait for something to be published? Does preprint data, is that valuable? This was a tension we had in producing our document. I would say we've come such a long way. Um, continue to look to, uh, new knowledge. Cause it probably will
come out if not weekly, uh, monthly.

Geralyn: Wonderful. Well, we've been discussing with Dr. Ty Gluckman the 2022 ACC expert consensus decision pathway on cardiovascular sequella of COVID 19 in adults, particularly related to myocarditis and other involvement you have just given us such great gems of information, and we are so grateful to y
ou for your time, Dr. Gluckman. We very much appreciate.

Dr. Gluckman: Absolutely. My pleasure. Thanks for having me.

Geralyn:  Thank you so much. This is your host Geralyn Warfield and we will see you next time.

Thank you for listening to Heart To Heart Nurses. We invite you to visit pcna.net for clinical resources, continuing education, and much more.