key: cord-1055719-l8i6xwn8 authors: Mechanick, Jeffrey I.; Rosenson, Robert S.; Pinney, Sean P.; Mancini, Donna M.; Narula, Jagat; Fuster, Valentin title: Coronavirus and Cardiometabolic Syndrome: JACC Focus Seminar date: 2020-10-27 journal: J Am Coll Cardiol DOI: 10.1016/j.jacc.2020.07.069 sha: f7a44a94e03efe7d3d387123bd2228f4f856c634 doc_id: 1055719 cord_uid: l8i6xwn8 The coronavirus disease 2019 (COVID-19) pandemic exposes unexpected cardiovascular vulnerabilities and the need to improve cardiometabolic health. Four cardiometabolic drivers—abnormal adiposity, dysglycemia, dyslipidemia, and hypertension—are examined in the context of COVID-19. Specific recommendations are provided for lifestyle change, despite social distancing restrictions, and pharmacotherapy, particularly for those with diabetes. Inpatient recommendations emphasize diligent and exclusive use of insulin to avert hyperglycemia in the face of hypercytokinemia and potential islet cell injury. Continuation of statins is advised, but initiating statin therapy to treat COVID-19 is as yet unsubstantiated by the evidence. The central role of the renin-angiotensin system is discussed. Research, knowledge, and practice gaps are analyzed with the intent to motivate prompt action. An emerging model of COVID-related cardiometabolic syndrome encompassing events before, during the acute phase, and subsequently in the chronic phase is presented to guide preventive measures and improve overall cardiometabolic health so future viral pandemics confer less threat. CARDIOMETABOLIC TARGETS ABNORMAL ADIPOSITY. Obesity is a major global problem. According to the World Health Organization, over 1.9 billion people age $18 years were overweight (39%) or obese (13%) in 2016, with 40 million children age <5 years overweight/obese in 2018 (4). Obesity is defined by the body mass index (BMI), which despite adjustments based on ethnicity, remains inadequate as a cardiovascular risk stratifier (5). Consequently, adiposity-based chronic disease has been developed as a new framework incorporating abnormal adiposity amount, distribution, and function, along with clinical complication severity (5). Not surprisingly, abnormal adiposity is a key driver, not only for obesity-related complications, but also insulin resistance, inflammation, type 2 diabetes (T2D), and CVD (1,2,5,6). A principal mechanism of abnormal adiposity leading to CVD is the accumulation of inflammatory pericardial/epicardial fat (1). This ectopic adipose tissue secretes more type II phospholipase A2 with ischemia, leading to more phospholipid hydrolysis, local free fatty acids, nerve impulse disruption, and arrhythmia; vascular inflammation, atherosclerosis, and arterial stiffness; cardiomyocyte fibrosis/apoptosis and left ventricular hypertrophy; and aortic valve sclerosis (1,7). Because this pathological adiposity results, in part, from unhealthy lifestyles, and is poorly detected with conventional anthropometrics, many people are at increased risk for cardiac injury. interleukin-2, -7, and -10 (52). Although many patients with COVID-19 take a statin, the use of statins to specifically manage viral illnesses remains unclear. In cell culture studies with human alveolar epithelial cells, H5N1 (influenza A) infection induced cytokine production (53) . Moreover, suppression of sterol biosynthesis with simvastatin reduced viral replication and cytokine production at a farnesylation step (54) . Nevertheless, combined treatment with simvastatin did not enhance the efficacy of oseltamivir in mice (55) . Also, atorvastatin mediates epigenetic histone modifications and ACE2 up-regulation in a rabbit atherosclerosis model (56) . Patients with Management per guidelines *Some adults may develop autoimmune ß-cell destruction and a T1D picture, possibly with DKA, at later ages (latent autoimmune diabetes in adults); this state may persist as T1D, revert to T2D, or resolve. †Insulin drips should be used judiciously to avoid unnecessary exposures of personnel to COVIDþ patients. Alternatives include more aggressive subcutaneous insulin dosing (e.g., q6h NPH þ correction rapid-acting insulin), use of intravenous chromium, and permissive underfeeding until glycemic target achieved (140 to 180 mg/dl). ‡Some patients with T1D are treated with SGLT2i. §Patients with T2D may be treated with lifestyle change, oral medications, noninsulin injectables, insulin, and/or metabolic procedures. CIRCS ¼ coronavirus disease-related cardiometabolic syndrome; CKD ¼ chronic kidney disease; CMBCD ¼ cardiometabolic-based chronic disease; CVD ¼ cardiovascular disease; DKA ¼ diabetic ketoacidosis; GLP1ra ¼ glucagon-like peptide-1 receptor agonist; SGLT2i ¼ sodium-glucose co-transporter 2 inhibitor; T1D ¼ type 1 diabetes; T2D ¼ type 2 diabetes. Practice gaps for HTN can be addressed with greater use of home BP monitoring, telemedicine visits with HCPs, and wearable technologies to increase physical activity. 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