key: cord-0937425-905y7gbw
authors: Gregory, Ann T.; Denniss, A. Robert
title: Heart, Lung and Circulation in the COVID-19 Era: About COVID-19, Not Just About COVID-19
date: 2021-11-03
journal: Heart Lung Circ
DOI: 10.1016/j.hlc.2021.10.001
sha: 1a9a81dbea124fbe9d07bc501216735b4a64abdf
doc_id: 937425
cord_uid: 905y7gbw

nan

In March 2020, our world entered the COVID-19 era [1] , and we have all since been experiencing waves of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic [2] . The effect of COVID-19 on our populations and health care systems has been, and continues to be, significant. The global pandemic has also affected scientific medical publishing, with an acknowledged disrupting effect, including a faster track to peer review and on-line publication for COVID-19 submissions but with stress on the peer review and publication of non-COVID-19 research [3] . At the recent virtual 69 th Annual Scientific Meeting of the Cardiac Society of Australia and New Zealand (CSANZ), Heart, Lung and Circulation (HLC) presented a joint, invited session with the European Heart Journal about their respective journal highlights in 2020, chaired by HLC's Editor-in-Chief Professor A. Robert Denniss. This editorial presents an overview of HLC's highlights in the 2020 volume (Volume 29), including those presented in that session; it also proposes some likely highlights of the current 2021 volume (Volume 30), which ends with this December 2021 edition. How is the COVID-19 pandemic affecting Heart, Lung and Circulation content? Is it all about COVID-19 now? Is any other published content also attracting attention?

There is no question that COVID-19 dominated the Heart, Lung and Circulation's hit-list in 2020, with about half of the combined "top 10" lists of most cited articles (Table 1) , most downloaded articles (Table 2) , and articles with most on-line attention (Table 3) , being directly related to Contributions, all available freely as part of the Journal's online Digital Collection of COVID-19 articles, addressed the acute cardiovascular issues, changes in model of care, and possible long-term implications [4] .

With a high of 25 citations (Scopus) at time of writing, Dhakal et al.'s narrative review SARS-CoV-2 Infection and Cardiovascular Disease: COVID-Heart summarised cardiovascular disease management in COVID-19 patients, including management of fulminant myocarditis, life-threatening arrhythmias and refractory shock [5] . Arnold's discussion paper, which suggested a possible role of the renin-angiotensin system (RAS) in the pathophysiology of COVID-19 was among the most requested articles [6] , as was Kasal et al.'s review of COVID-19 and microvascular disease, also with a focus on the RAS [7] .

Changes in models of care were outlined in a series of 10 comprehensive CSANZ Statements in different aspects of cardiovascular practice-with a quartet represented in the year's 10 tables relating to interventional cardiology services [8] , acute heart failure and assessing the critically ill [9] , rural and remote cardiology [10] and cardiac rehabilitation and secondary prevention [11] . All statements addressed how to provide safe care for all patients and health care workers while managing COVID-19 or the risks of exposure to the SARS-CoV-2 coronavirus.

While telehealth and other e-health initiatives were foreshadowed by Nicholls et al. to have positive implications for longer term use beyond the pandemic [11] , concerns were raised about other not-so-positive longer-term implications-a "tsunami" of non-COVID-19 acute cardiac conditions as a consequence to a COVID-19-related delay in seeking care for chronic cardiovascular conditions [12, 13] , as well as the mental health and psychosocial challenges of the pandemic [14] -appreciated all too readily by those of us living in lockdown conditions for extended periods of time.

Perhaps this COVID-19 domination in 2020 should come as no surprise: COVID-19 is at the top (ie, number 1) of the popular US commentator Dr John Mandrola's Top 10 in Cardiology for 2020: Mandrola wrote that: "before 2020, heart disease and cancer dominated medical news: the COVID-19 pandemic reset all that" [15] .

There are other remarkable "non-COVID-19" contributions in the same volume of Heart, Lung and Circulation. For example, to-date, Zentner et al.'s co-authored CSANZ Position Statement on the Management of People with a Fontan Circulation has been downloaded more times than any other article published in the 2020 volume. It is notable for its truly collaborative approach involving not only a multidisciplinary group of health care providers but also individuals with a Fontan circulation and their families [16] .

The Special Issue for the Year 2020-about Genetic Heart Diseases-with esteemed Guest Editors Semsarian (now Editor-in-Chief of Circulation: Genomic and Precision Medicine), Atherton and Skinner, has also garnered much interest [17] . This compilation of commissioned State-of-the-Art reviews, published in April 2020, was intended to be launched at the International Clinical Cardiovascular Genetics Conference meeting-since "rescheduled" twice (from May 2020 to May 2021, and then again to May 2022) due to COVID-19 pandemic-related lockdowns and travel restrictions. The most highly requested article in the issue has been Ingles et al.'s review on genetic testing in inherited heart disease [18] , since referenced in the American Journal of Preventive Cardiology's succinct overview of things to know about 10 common cardiovascular disease (CVD) risk factors applicable to preventive cardiology, including genetics [19] . Ingles et al. describe the specifics of genetic testing for a range of disease settings-hypertrophic, dilated, restrictive and arrhythmogenic cardiomyopathies, left ventricular noncompaction, catecholaminergic polymorphic ventricular tachycardia, familial hypercholesterolaemia, long QT and Brugada syndromes, and heritable thoracic aortic disease. Given the nuances and challenges of cardiac genetic testing, they advise the consensus is that the best outcomes for the patient and their family are achieved when genetic testing is offered in a specialised multidisciplinary clinic with access to genetic counselling [18] .

Skinner et al.'s comprehensive review on the clinical and genetic aspects of cardiac ion channelopathies that lead to sudden cardiac death is among the most cited articles in Heart, Lung and Circulation within the past 3 years. Cardiac ion channelopathies are described as the prime suspects in sudden death with a negative autopsy; each channelopathy has its own electrocardiographic (ECG) signature, typical mode of presentation, and most-commonly related gene [20] .

Also drawing attention in the Genetic Heart Diseases edition is Bart et al.'s review on amyloid cardiomyopathy [21] . Considered an under-diagnosed disorder, amyloid cardiomyopathy is characterised by extracellular deposition of amyloid fibrils that form due to misfolding of secreted light chains or transthyretin protein. Until the very recent advent of disease-modifying treatments, amyloid cardiomyopathy has generally been considered a progressive, and potentially fatal, disease. An "inaugural treatment" for transthyretin amyloid cardiomyopathy, tafamidis (a benzoxazole derivative), is listed as number 3 in the Cleveland Clinic's "Top 10" medical innovations for 2020 [22] . In recent deliberations for Heart, Lung and Circulation's annual Best Review Prize, Bart was Highly Commended as first author of this review.

Heart, Lung and Circulation's Best Review Prize formally recognises and acknowledges the efforts of early career authors and was first awarded in 2015 [23] . The Best Review Prize for 2021 (judged for the 2020 volume) was awarded to Harky, a UK-based cardiothoracic surgery registrar, as first author of the narrative review about the rapidly evolving and expanding practice of robotic cardiac surgery [24] , including in coronary revascularisation, mitral valve surgery, atrial fibrillation surgery, left ventricular lead implantation, atrial septal defect closure, and summary for atrial myxoma; the use of robotics in atrial valve surgery is reported to be very much in the early phase of development. Harky et al.'s review has 19 Scopus citations at time of writing. Also Highly Commended was Thakkar, first author of a systematic review about masked hypertension [25] .

The Journal now also recognises outstanding original research each year with three distinct classes of awards: High Impact Awards, first awarded in 2017 [26] ; the Franklin Rosenfeldt Award, named in honour of this Journal's first Editor-in-Chief, for innovation in clinical research in the field of cardiac and thoracic surgery, first awarded in 2019; and the Cardiovascular Science Award, also first awarded in 2019. Both the Franklin Rosenfeldt Award and the Cardiovascular Science Award recognise outstanding contributions from an Australasian-based author (or authors).

Although Heart, Lung and Circulation's High Impact Awards can go to research conducted by authors located anywhere in the world (and address any topic), winners for the 2020 volume (awarded in 2021) were all based in Australia. Two (2) patients who underwent coronary angiography in a prospective cohort study, found that an elevated triglycerides to high density lipoprotein cholesterol (TG/HDL-C) ratio is an independent predictor of long-term all-cause mortality and strongly associated with an increased risk of a major adverse cardiac event [27] . Tran-Duy et al. received a High Impact Award for most downloads-they developed a seven-factor risk score that could stratify 5-year risk of Heart, Lung and Circulation in the COVID-19 Era cardiovascular disease in an Indigenous Australian cohort to a greater degree compared to a recalibrated Framingham risk score [28] .

The Franklin Rosenfeldt Award for the 2020 volume was awarded jointly to Chatterton et al. [29] for reporting a prospective pilot study of a preoperative predictor of postoperative bleeding (and need for subsequent transfusion) and Royse et al. [30] for presenting early experience of a novel reconstruction for total arterial coronary revascularisation-two radial arteries (RA) joined as a Y graft (RARAY).

Regrettably, no Cardiovascular Science Award could be given in 2021 (for the 2020 print year), as there were no qualifying Australasian-authored contributions in that volume. This is disappointing, as this Journal is committed to supporting the cardiovascular science research sector by publishing articles across the spectrum of relevance to cardiovascular health-from bench to bedside and beyond. In a Discussion Paper, Climie et al. presented the results of an online survey of cardiovascular research employees or students conducted in 2019-prior to the COVID-19 pandemic [31] . They concluded that a lack of strategic funding and longterm job security threatened to have profound effects on cardiovascular researcher retention in Australia. Strategic solutions proposed included: diversification of career pathways and funding sources; and, moving from a competitive to a collaborative culture. The challenges that cardiovascular researchers face is an international concern, with Climie and Marques writing in Circulation about the impact, strategies, and opportunities for early and mid-career cardiovascular researchers during the COVID-19 pandemic [32] . Strategic opportunities including promoting awards, and we hope to receive more submissions in 2022 that can be considered for Heart, Lung and Circulation's Cardiovascular Science Award.

On balance, and notwithstanding the arrival of the COVID-19 era, the leading contributions in 2020 include position statements, theme issues, discussion papers on contemporary issues, and award-winning original research and reviews covering a broad range of relevant topical issues-including but not only related to COVID-19.

Although 2021 is nearly but not yet complete, and the relevant bibliometric data is to be collected and analysed for some time yet, we are expecting the leading contributions to follow in the same rich vein.

2021 has seen further articles about COVID-19 but rather than initial, well-considered pandemic guidance offered by experts and projections and predictions of likely effects to come, we are now seeing original contributions and commentary about the lived experience from the "fields of battle" in Australia and elsewhere in terms of: the acute disease, its manifestations and complications [33] [34] [35] [36] [37] [38] ; the adaptations to and opportunities in COVID-19 care [39, 40] and in other care settings [41] ; the effects of the COVID-19 pandemic on diagnostic cardiac procedural volumes [42, 43] and cardiac surgery [44, 45] ; and, more recently, the reported side-effects of COVID-19 vaccination [46, 47] .

Among the findings reported or reviewed: the echocardiographic manifestations of COVID-19 are many [34] ; troponin elevation was common but clinical sequelae were uncommon in patients with COVID-19 requiring hospitalisation in Australia [36] ; and, atrial fibrillation was determined to be a predictor of mortality in high risk COVID-19 patients [37] .

The Remote Device Interrogation Kiosks (ReDInk) allow for remote testing of pacemakers and implantable cardioverterdefibrillators in a rural setting [40] , where previously device checks had been performed in face-to-face clinics by visiting cardiologists and technicians. In fact, increased access to telemedicine through novel practice and policy changes is ranked number 7 in the Cleveland Clinic's "Top 10" medical innovations for 2021, with regulators moving quickly to reduce barriers to telehealth, appreciating that these tools can speed access to health care while protecting both health care workers and community members [48] .

O'Sullivan et al. assessed the early impact caused by the COVID-19 pandemic on cardiac procedure volume in Oceania, finding a significant reduction especially in transoesophageal echocardiography and stress tests [42] . They say longer term evaluation will be important to assess for negative patient outcomes which may relate to deferral of usual models of care in cardiology. More recently, in a study reported in this edition of the Journal, McNamara et al. found their local hospital's early response to the COVID-19 pandemic also led to a documented reduction in cardiac surgery service delivery albeit with no change in urgency or type of surgery [44] .

Reports of myocarditis after COVID-19 vaccination, especially mRNA vaccination, have come to notice-thankfully, it is found to be mostly mild, and to respond well to treatment, with relatively rapid symptom improvement [46, 49] . Heart, Lung and Circulation has also published a novel case report from Swiss authors of Takotsubo cardiomyopathy after mRNA COVID-19 vaccination [47] .

In 2021, as in 2020, there have been CSANZ Position Statements [50, 51] , as well as landmark guidance documents from experts on enhancing the care of familial hypercholesterolaemia in Australia [52] , and about food consumption to prevent cardiovascular disease [53] . However, the CSANZ Position Statements have not been about COVID-19 in 2021; rather they have been joint statements endorsed by both CSANZ and the Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) addressing operational and institutional requirements for transcatheter valve therapies in Australia: a completely new statement for transcatheter mitral valve therapies [50] , and an updated statement for transcatheter aortic valve therapies [51] . Davies et al. comment on the practical application of these standards [54] .

While we await data to indicate which original research articles published in 2021 will have the most impact, one that is already showing promise is a report from the Mackay Heart Failure Study [54] . At time of writing, the 2020-2021

Heart, Lung and Circulation in the COVID-19 Era paper with the most recent online attention, as measured by alternative metrics (PlumX metrics), was about a study conducted in a typical regional centre in Australia and reported good news-excellent compliance with guideline directed medical therapy and a good prognosis for most patients in terms of both symptoms and survival [55] . 2021 has seen not just one but two special issues published: first, the Women's Heart Health edition in January 2021 [56] , and more recently, the Vascular Ageing edition [57] , both linked to annual CSANZ Scientific meetings. The Women's Heart Health edition has been freely available as the "sample issue" of Heart, Lung and Circulation for all of 2020; Geraghty et al.'s review on Cardiovascular disease in women: from pathophysiology to novel and emerging risk factors has been downloaded more than any other article in the edition [58] . This review points out that cardiovascular disease pathophysiology differs between the sexes, with women more likely to suffer from microvascular coronary disease, endothelial dysfunction, and heart failure with preserved ejection fraction when compared with men-who are more likely to suffer macrovascular disease or heart failure with reduced ejection fraction. Further, that risk factors are often underrecognised and under-treated in women.

The Vascular Ageing edition, linked also to the international Association for Research into Arterial Structure and Physiology (ARTERY) 2021 conference (arterysociety.org), has been published as the November 2021 edition. An overarching concept addressed by this special issue is that one's vascular age may differ from one's calendar age, and there are ways that vascular age could not only be measured but also moderated.

Planning forward into 2022, Heart, Lung and Circulation has announced a Call for Papers for a Special Issue on Environment, Climate and Cardiovascular Health, with guest editors, Redfern, Ferguson, Figtree, and Raman (https://bit. ly/3DleYaX), and invite contributions that examine the impact of environment and climate, pollution, extreme weather events and more on cardiovascular health, as well as potential solutions to current and future cardiovascular health impacts.

Overall, in the COVID-19 era-to-date, Heart, Lung and Circulation has published on a range of responses to, and more recently, the effects of, the COVID-19 global pandemic on health care services and their utilisation. Heart, Lung and Circulation is also publishing on much more, including expert guidance and other articles on current topics of importance or interest in cardiovascular medicine worldwide as identified by expert commentators [15, 22, 41, 47] . Special Issues address themes from the general (women's heart health; environment, climate and cardiovascular health) to the specific (genetic heart diseases; vascular ageing). As the COVID-19 era transitions from pandemic to post-pandemic, and perhaps endemic, status, this Journal-with the invaluable support of our community of readers, authors, researchers, peer reviewers and editors-looks forward to publishing further reports related to the responses and activities, interests and needs of the Australasian, regional and global cardiovascular community-About COVID-19 but Not Just About COVID-19.

Cardiovascular disease and COVID 19: Australia and New Zealand consensus statement

COVID-19 and Heart, Lung and Circulation: Riding the 2020 waves of change in Australia & New Zealand

How a torrent of COVID science changed research publishing-in seven charts

Cardiovascular and logistic issues associated with COVID-19 pandemic

SARS-CoV-2 infection and cardiovascular disease: COVID-19 heart

COVID-19 -Does this disease kill due to imbalance of the renin angiotensin system (RAS) caused by genetic and gender differences in response to viral ACE attack?

COVID-19 and microvascular disease: Pathophysiology of SARS-CoV-2 infection with focus on the reninangiotensin system

Interventional council of CSANZ and COVID-19 Interventional cardiology working group. Consensus guidelines for interventional cardiology services delivery during COVID-19 pandemic in Australia and New Zealand

COVID-19 and acute heart failure: Screening the critically ill-A position statement of the Cardiac Society of Australia and New Zealand (CSANZ)

Rural and remote cardiology during the COVID-19 pandemic: Cardiac Society of Australia and New Zealand (CSANZ) Consensus Statement

Optimising secondary prevention and cardiac rehabilitation for atherosclerotic cardiovascular disease during the COVID-19 pandemic: A position statement from the Cardiac Society of Australia and New Zealand (CSANZ)

Cardiovascular disease in the post-COVID-19 era-the impending tsunami?

Collateral damage: The cardiovascular cost of suppressing COVID-19 transmission in Australia

Mental health and psychosocial challenges in the COVID-19 pandemic: Food for thought for cardiovascular health care professionals

Mandrola's top 10 in cardiology for

Management of people with a Fontan circulation: a Cardiac Society of Australia and New Zealand position statement

Genetic cardiovascular conditions-It's all about family

Genetic testing in inherited heart diseases

Ten things to know about ten cardiovascular risk factors

Channelopathies that lead to sudden cardiac death: clinical and genetic aspects

Cleveland Clinic unveils top 10 medical innovations for 2020

Heart, Lung and Circulation Evolves: A fond farewell to our 25 th anniversary year and a warm welcome to new initiatives

The future of open heart surgery in the era of robotic and minimal surgical interventions

Masked hypertension: a systematic review

Making an impact: a new research prize for Heart, Lung and Circulation

Elevated triglycerides to high-density lipoprotein cholesterol (TG/HDL-C) ratio predicts long-term mortality in high-risk patients

Development and use of prediction models for classification of cardiovascular risk of remote Indigenous Australians

Platelet activity measured by VerifyNow® Aspirin Sensitivity Test identifies coronary artery bypass surgery patients at increased risk for postoperative bleeding and transfusion

RARAY Operation: Operative description and early results for achieving total arterial coronary revascularisation

Australian Cardiovascular Alliance. Lack of strategic funding and long-term job security threaten to have profound effects on cardiovascular researcher retention in Australia

Impact, strategies and opportunities for early and mid-career cardiovascular researchers during the COVID-19 pandemic

Cardiac injury and outcomes of patients with COVID-19 in New York City

Echocardiographic manifestations in COVID-19: a review

The counter regulatory axis of the lung renin-angiotensin system in severe COVID-19: pathophysiology and clinical implications

Cardiac complications in patients hospitalised with COVID-19 in Australia

Atrial fibrillation as a predictor of mortality in high risk COVID-19 patients: a multicentre study of 171 patients

Atrial fibrillation in COVID-19: therapeutic target or grave omen?

Reducing potential COVID-19 exposure with coronary computed tomography for left atrial appendage assessment: a tool for our time

Remote Device Interrogation Kiosks (ReDInK)-Pharmacy kiosk remote testing of pacemakers and implantable cardioverter-defibrillators for rural Victorians. A novel strategy to tackle COVID-19

Extracorporeal membrane oxygenation in acute respiratory distress syndrome: how do we expand capacity in the COVID-19 era?

INCAPS COVID Investigators Group. Impact of COVID-19 on diagnostic cardiac procedural volume in Oceania: The IAEA Non-Invasive Cardiology Protocol Survey on COVID-19 (INCAPS COVID)

Procedural volumes in the era of COVID: the risk versus benefit trade-off

The impact of COVID-19 on the provision of adult cardiac surgery at a dedicated COVID hospital in Australia

Cardiac surgery in Australia during the COVID-19 global pandemic

Myocarditis, pericarditis and cardiomyopathy after COVID-19 Vaccination

Takotsubo cardiomyopathy after mRNA COVID-19 vaccination

Cleveland Clinic unveils top 10 medical innovations for 2021

What's new in cardiovascular medicine

Cardiac Society of Australia and New Zealand (CSANZ) and Australia and New Zealand Society of Cardiac and Thoracic Surgery (ANZSCTS). Operator and institutional requirements for transcatheter mitral valve therapies in Australia: a CSANZ and ANZSCTS position statement

2021 CSANZ and ANZSCTS position statement on the operator and institutional requirements for a transcatheter aortic valve implantation (TAVI) program in Australia

FH Australasia Network Consensus Working Group. Integrated guidance for enhancing the care of familial hypercholesterolaemia in Australia

Practical guidance for food consumption to prevent cardiovascular disease

Position Statements for transcatheter valve therapies in Australia: accreditation standards and Heart Team opportunities

Heart Failure Study: examining the root causes, compliance with guideline-based therapy and prognosis

Heart disease in women: where are we now and what is the future?

Vascular ageing: a key frontier in the fight against cardiovascular disease

Cardiovascular Disease in Women: From Pathophysiology to Novel and Emerging Risk Factors

From "The year in cardiovascular medicine 2020: Journal highlights" session at CSANZ 2021, 6 August 2021. Representing Heart, Lung and Circulation-presenters Domenica Zentner (Fontan: The position statement experience), Rachel Climie (Cardiovascular researcher retention in Australia), Jonathan Skinner (Genetic Heart Diseases-It's all in the family), and panellist, Salvatore Pepe. Representing European Heart Journal-Filippo Crea, Harry Crijns and Rudolf De Boer.