key: cord-0694299-hscu50ss
authors: O'Connor, Dr. Christopher M.
title: COVID-19 Fatigue: Not So Fast
date: 2020-06-04
journal: JACC Heart Fail
DOI: 10.1016/j.jchf.2020.06.001
sha: 25516169658b744eaa59200c8dc9f8a23ba14520
doc_id: 694299
cord_uid: hscu50ss

nan

JACC: HF Editors Page July 2020 COVID-19 Fatigue: Not So Fast With over 5 million cases of COVID-19 infection since the outbreak in Wuhan, China in late 2019, we have been focused as healthcare providers in leadership on the acute manifestations of the illness, and preparing our health systems for a rapid increase in moderate-severe cases requiring hospitalization.

Over the past several months, my days have been full of change in the governance and culture of the health system. These changes include some of the following:

1. Setting up a broad-based governance structure that goes well beyond our employed faculty physicians with community physicians represented on our leadership team. 2. Supporting our leadership to prepare for this infectious pandemic by converting intensive care unit beds and other units with reverse airflow capabilities to minimize risk. 3. Developing supply chain mechanisms to support personal protective equipment (PPE) materials in large quantities. 4. Developing algorithms for treatment along a category of mild, moderate, and severe, that included the use of ECMO in the most severe cases.

We had unique collaboration across the multiple hospitals in our system to support sharing of healthcare providers, ventilators, and patients requiring ICU capabilities. Seven days a week, we were conversing on best practices and sharing information, so that we can quickly adapt our care models. These include the following: 1. Temporarily allowing our cardiovascular fellows to work as hospitalists in COVID units. 2. Removing hospitalists from our heart failure service to free them up for other areas in the health system. 3. Allowing heart failure doctors to become primary care physicians on their respective services. 4. Expanding our ECMO program to support Venovenous (VV) extracorporeal membrane oxygenation (ECMO) across the health system in the medical intensive care units to a greater degree. 5. Training cardiovascular specialists in advanced respiratory failure management. 6. Converting a number of cardiovascular units to COVID units with specialization in use of prone ventilation and high-flow oxygen therapy. 7. Committing our research infrastructure to support clinical trials of COVID therapy interventions.

Our days have been consumed with COVID management, while ensuring our cardiovascular patients receive safe and effective care. To our surprise, having a reduction in the number of STEMI patients, stroke patients, and aortic dissection patients coming to the hospital, reinforced the indirect consequences of COVID on cardiovascular morbidity and mortality. As we continue to improve our algorithms of care and stabilize our efforts, we began the discussion of reopening to a new normal of cardiovascular care for patients who had delayed procedures. In this capacity, using universal testing, broad-based PPE, screening, mitigation, and isolation, we began to serve our cardiovascular patient population. All of this occurred over a 12-week period has left many of our providers fatigued, tired, burned out, and questioning the future.

And yet, while the acute phase is beginning to stabilize and we are getting a handle on the new normal, the chronic phase of COVID-19 will continue for years to come, with potentially half of the 5 billion people in the world becoming affected with COVID. In addition, many who survive may have persistent symptoms. What are these symptoms? Some include fatigue, dyspnea, and lack of energy. How does this translate into clinical diagnoses? In a case that I was involved with, a 40-year-old triathlete who developed COVID-19 illness to a moderate degree who stayed at home with symptoms not requiring hospitalization, had residual fatigue six weeks post illness. The patient had an N-terminal-pro BNP (NT-proBNP) level that was significantly elevated and echocardiographic evidence of recovered myocarditis with impairment of the myocardium.

Will this be the future, that there will be a significant increase in cardiopulmonary compromise of patients who have suffered COVID-19 illness even in the mild-tomoderate cases not requiring hospitalization? Furthermore, there are many other aspects to this condition. The pulmonary conditions can include pulmonary fibrosis, restrictive lung disease, pulmonary hypertension, and chronic pulmonary thromboembolic disease. All of these conditions will cause impaired exercise tolerance, dyspnea on exertion, fatigue and reduced capacity. With respect to cardiovascular conditions, up to 10% of ICU patients may develop acute myocarditis by evidence of increased troponin and natriuretic peptic levels. (1) Residual elevation of markers may persist for many weeks. The patients may exhibit evidence of recovered myocarditis with diastolic dysfunction or persistent reduced ejection fraction with systolic dysfunction. Cardiac arrhythmias have been noted to be common during hospitalization and may continue post hospitalization. (2) In addition, the intersection of pulmonary restrictive disease with cardiovascular disease may result in increased pulmonary vascular blood pressure and pulmonary hypertension, causing significant impairment of exercise performance. Additional organ systems that may be affected include the brain, liver, and kidneys to name a few. Myalgic encephalomyelitis/chronic fatigue syndrome has found to be common in post-viral illnesses and COVID-19. (3) This condition of chronic fatigue and depressive symptoms may continue for the long term. Depression, anxiety, and posttraumatic stress syndrome are all potential long-term sequelae of the COVID-19 illness. Chronic liver disease has been described in these patients as well as chronic kidney disease. It is believed that COVID-19 patients may contribute up to a 5-10% increase in chronic kidney disease over the next several years.

Thus, our fatigue for the care of the acute COVID-19 patients is understandable. Our contributions have been remarkable, but we must be prepared for the long term. COVID-19 survivors will continue to have important symptoms and impairment of functional status that will require us to be diligent in our understanding and care.

I propose that we begin to establish cardiopulmonary COVID-19 clinics. This would be a multidisciplinary clinic with pulmonologists, cardiologists, and the multidisciplinary team evaluating recovered COVID-19 patients who continue to have symptoms. In this capacity, they could be evaluated and their information would be categorized in a database beyond signs and symptoms. Moreover, a comprehensive biomarker analysis would be performed along multiple pathways including inflammatory, hemodynamic, myocardial injury, and other biomarkers to better understand and follow this condition. From the standpoint of imaging, comprehensive transthoracic echocardiography with a particular emphasis on measurement of diastolic dysfunction and RV function should be made. Pulmonary CT scans should be conducted to look for early evidence of pulmonary fibrosis, thromboembolic disease, and secondary evidence of pulmonary hypertension.

Finally, cardiopulmonary exercise studies should be performed to serve as a benchmark for cardiovascular impairment and to serially follow these patients if indicated. It is postulated that these patients may be excellent candidates for exercise intervention, as was done with the HF-ACTION Trial, and with the recently completed REHAB-HF study, to improve functional status and quality of life. (4, 5) COVID-19 is not a short term acute healthcare problem that will go away and not return. COVID-19 is here today, and has caused enormous fatigue on our patients and healthcare providers in this three-month acute phase. The chronic phase will consist of an everlasting number of patients with impaired functional status and quality of life that we should address as heart failure physicians with our multidisciplinary teams.

End-Stage Heart Failure with COVID-19: Strong Evidence of Myocardial Injury by 2019-nCoV

COVID 19 and heart failure: from infection to inflammation and angiotensin II stimulation. Searching for evidence from a new disease

COVID-19 Clinical Trials: A Primer for the Cardiovascular and Cardio-Oncology Communities

Efficacy and Safety of Exercise Training in Patients with Chronic Heart Failure: HF-ACTION Randomized Controlled Trial

A Novel Rehabilitation Intervention for Older Patients with Acute Decompensated Heart Failure: The REHAB-HF Pilot Study