A scientific statement outlining unique considerations and suggestions for managing heart failure patients during the COVID-19 pandemic was issued in September 2021 by the Heart Failure Society of America, and Anuradha Lala, MD, Assistant Professor of Medicine (Cardiology) at the Icahn School of Medicine at Mount Sinai, led the effort to advance this work. The document, published in the Journal of Cardiac Failure, provides physicians with guidance on how to prevent heart failure and heart transplant patients from getting COVID-19 given their need for frequent monitoring; how to care for them if they get the virus; and the importance of vaccinations for both immunocompromised patients and those taking immunosuppressants.
This work is important to streamline care and protect this high-risk patient population. A Mount Sinai study conducted by Dr. Lala and published in November 2020 in the Journal of the American College of Cardiology found that heart failure patients hospitalized with COVID-19 are nearly twice as likely to die and at triple the risk of intubation when compared to those without the pre-existing heart disease.
The scientific statement is the first to outline the issues unique to the nexus of heart failure and COVID-19, says Dr. Lala, the senior author. “We believe this comprehensive document will be useful for internists and specialists alike, as well as patients and caregivers. Unfortunately, hospitals continue to face a surge of patients with COVID-19, including patients with heart failure and/or history of mechanical circulatory support and heart transplant,” she says.
“Though much progress has been made in terms of our understanding of pathophysiology, development of vaccines, and processes of care, much work remains in understanding how the virus specifically exerts effects on the cardiovascular system and which treatments improve outcomes. Perhaps most importantly, this document underscores the need for our patients to be vaccinated and in some cases receive a booster vaccine.”
Dr. Lala and a team of international heart failure cardiologists, cardiothoracic surgeons, infectious disease physicians, pharmacists, and nurses developed the document based on accumulated data, peer-reviewed studies, and personal experience treating heart failure patients and heart transplant recipients throughout the COVID-19 pandemic. Their scientific statement outlines COVID-19’s impact on the heart and implications for clinical care. Several key points were highlighted:
Telehealth for treatment and technology developed for remote monitoring of heart failure can help limit the risk of COVID-19 exposure for nonhospitalized patients, and physicians are increasingly relying on these tools.
The authors provide a suggested algorithm for SARS-CoV2 testing of pre-transplant recipients and donors. For patients waiting for a heart transplant, COVID-19 testing should take place before transplant surgery, in addition to testing of the donor. Transplantation should be postponed if there is a positive test, even if the patient does not have symptoms. This underscores the importance of mask wearing and social distancing and vaccination for patients on the transplant waiting list.
Ideally and when feasible, health care workers caring for COVID-19 patients should avoid caring for hospitalized heart failure patients who are not COVID-19 positive.
Heart failure patients and heart transplant recipients should be vaccinated, and patients who are immunosuppressed, including solid organ transplant recipients, should receive a third dose of mRNA COVID-19 vaccine, according to the Centers for Disease Control and Prevention (CDC).
Despite initial fear that cardiac medications could lead to high risk of COVID-19, evidence has not supported this. Cardiac medications that are lifesaving in the case of heart failure with reduced ejection fraction should be continued.
Patients with heart failure should be considered eligible for all immunomodulating therapies (including monoclonal antibodies and steroids) used to treat COVID-19 patients, similar to populations without heart failure. Patients with heart failure may have more fluid overload when on these therapies so it is important for physicians to look for and assess this, and then provide guidance on increasing diuretic medication.
Vaccination rates remain lower than ideal for this vulnerable population. Designated efforts should be made to educate and inform patients of risks if they contract COVID-19 and to encourage vaccination as much as possible.
“This scientific statement rests on data accumulated to date but are subject to change as the field and research advances. Nonetheless, it is an important first step outlining unique considerations for this high-risk population amid this ongoing, virulent pandemic,” adds Dr. Lala.
Dr. Lala co-chaired the development of this scientific statement with Ankeet Bhatt, MD, a Clinical Research Fellow with the Division of Cardiovascular Medicine at Brigham and Women’s Hospital.
Anuradha Lala, MD
Associate Professor of Medicine (Cardiology), and Population Health Science and Policy