Corona Virus as Atrial Fibrillation (afib)
What Do Afib Patients Need to Know About the Coronavirus (COVID-19)?
Here is some overall guidance for those with afib (the sources listed in parentheses are linked below).
Those at a higher risk of getting the coronavirus, and developing serious complications from it, are either:
Age 60 (65 per the CDC) or over, or
Have a chronic condition such as heart disease, heart failure, high blood pressure, diabetes, lung disease/COPD, cancer, kidney disease, liver disease, or other chronic conditions. (CDC)
Does afib alone, with no other risk factors, increase the risk of developing the coronavirus? This is a complicated area because we have so little data, but here is what we know currently:
From our discussions with various experts, many of whom have been on multiple guidelines committees, they have not seen any data to indicate one way or the other whether those with afib alone, with no other risk factors, are at higher risk.
The American Heart Association says that those with cardiovascular disease have an increased risk. In an interview, AHA’s chief medical officer for prevention, Dr. Eduardo Sanchez, included afib in the list of cardiovascular diseases. This area is evolving quickly, and they may have data that no one else has. (We will see if we can get the data behind this.)
The British Heart Foundation says: “If you have atrial fibrillation, there isn’t enough information at the moment to tell whether it or other abnormal heart rhythm problems put you at higher risk from coronavirus. It seems likely if you have well-controlled atrial fibrillation, that your risk is lower than for the groups mentioned.” (British Heart Foundation)
The Government in the United Kingdom posted guidance on social distancing for those at increased risk of severe illness. They listed risk factors such as those age 70 and over, diabetes, chronic kidney disease, and “chronic heart disease, such as heart failure.” Atrial fibrillation and high blood pressure were not explicitly listed. (UK Government)
Simply being on an anticoagulant does not put you at higher risk. (Anticoagulation Forum)
Those with cardiovascular disease (CVD) should be current on their influenza and pneumococcal vaccinations. (ACC and AHA)
Here are some specific facts of relevance to those with afib.
More than 80% of infected patients experience mild symptoms and recover without intensive medical intervention. (ACC)
Fatality rates increased by age, according to case reports from China. They were 8.0% among patients 70-79 and 14.8% among patients over 80. (ACC)
Between 25% and 50% of coronavirus patients mentioned in case reports from China already had pre-existing chronic conditions that increased their risk of getting the disease. (ACC)
Among coronavirus patients who were hospitalized, 40% had pre-existing cardiovascular or cerebrovascular (impaired blood flow to the brain) disease. (AHA)
Fatality rates were higher for those with the following pre-existing conditions:
Chronic respiratory disease: 6.3%
Cardiovascular disease: 10.5% (ACC)
The coronavirus appears to cause heart (cardiac) damage, particularly in those with pre-existing cardiovascular disease, as well as arrhythmias, and results in a higher risk of death. (American College of Cardiology, Journal of the American College of Cardiology)
In those hospitalized for coronavirus, as shown in case reports, 16.7% developed an arrhythmia, and 7.2% experienced an acute cardiac injury, in addition to other complications. Additionally, there were cases of heart failure and heart attacks reported. (ACC)
Why are heart disease patients affected so disproportionately?
Many afib patients have underlying heart disease, so this is especially relevant to them.
The coronavirus targets the lungs, which then have to work harder. The heart also has to work harder to get oxygen-rich blood to the body. Those with heart failure, which is common among those with afib, are especially affected as the heart has to work harder to pump effectively. (AHA)
Heart patients may have weakened immune systems, making it harder to fight off the virus. (AHA)
Heart patients with plaque build-up in the arteries are at risk of this virus disrupting the plaque and leading to blockage of an artery, thus leading to a heart attack. (AHA)
What damage does the coronavirus cause?
Those with heart disease, diabetes, lung disease, or other chronic conditions are more likely to be hospitalized and put in intensive care if they develop COVID-19. (New CDC data shows danger of coronavirus for those with diabetes, heart or lung disease, other chronic conditions)
The damage done by the coronavirus appears to be mimicking heart attacks. (A Heart Attack? No, It Was the Coronavirus and Study: STEMI Often Not What It Appears in COVID-19)
The risk of death increases dramatically when coronavirus patients have underlying cardiovascular disease. (Risk of death skyrockets when COVID-19 patients have both CVD and myocardial injury)
The coronavirus damages various organs in the body, including the heart, brain, and kidneys, likely due to two related mechanisms: (1) the coronavirus causes clots that go to the brain as strokes and the lungs as pulmonary emboli, and (2) the response of the body’s own immune system to the virus sends a storm of cytokines to attack the virus and ends up damaging the body’s own cells. Thus, some hospitals are using blood thinners (anticoagulants) for patients with COVID-19. Additionally, the virus appears to attack the kidneys as well. (Doctors keep discovering new ways the coronavirus attacks the body)
In patients with COVID-19, median survival increased from 14 days to 21 days with the addition of anticoagulant treatments. Some patients received apixaban or rivaroxaban, others received heparin, and some received tPA (used in treating strokes). Death rates didn’t vary between those treated with anticoagulants and those without, and bleeding rates did not increase for those on anticoagulants. (Evidence Builds Linking Anticoagulation to COVID-19 Survival)
Whether or not those with COVID-19 should receive anticoagulants if they are not already taking them needs further evaluation. New COVID-19 Treatment Guidelines from the National Institutes of Health that were developed in conjunction with the relevant medical societies and government agencies do not recommend starting anticoagulants in those not already on them.
What do afib patients on anticoagulants such as warfarin need to know?
If you get the coronavirus, you should generally continue to take your anticoagulant to prevent blood clots. (North American Thrombosis Forum)
For those on warfarin who get the coronavirus, it is unknown as to whether or not the INR will be affected. (Anticoagulation Forum)
For those who are self-isolating and on warfarin, in order to avoid the need for frequent blood checks during this time, it may be reasonable to transition to the newer blood thinners, called DOACs (direct-acting oral anticoagulants). The DOACs include Pradaxa (dabigatran), Xarelto (rivaroxaban), Eliquis (apixaban), and Savaysa (edoxaban). (Anticoagulation Forum, North American Thrombosis Forum)
Patients who are stable on warfarin may be able to have less frequent blood checks during this time. (Anticoagulation Forum)
What do afib patients on ACE or ARB medications need to know?
There have been news stories indicating that certain medications, angiotensin converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs), could increase the risk of infection and increase the severity of infection caused by the coronavirus. These essential medications are used for controlling high blood pressure, a condition that is common among a large percentage of those with afib.
The American College of Cardiology, the American Heart Association, and the Heart Failure Society of America released a joint statement urging those on these medications not to stop using them and calling for more research: "The continued highest standard of care for cardiovascular disease patients diagnosed with COVID-19 is top priority, but there are no experimental or clinical data demonstrating beneficial or adverse outcomes among COVID-19 patients using ACE-I or ARB medications," said Richard J. Kovacs, MD, FACC. "We urge urgent, additional research that can guide us to optimal care for the millions of people worldwide with cardiovascular disease and who may contract COVID-19. These recommendations will be adjusted as needed to correspond with the latest research." (HFSA/ACC/AHA)
The European Society of Cardiology Council on Hypertension issued a similar position on ACE-Inhibitors and Angiotensin Receptor Blockers: “This speculation about the safety of ACE-i or ARB treatment in relation to COVID-19 does not have a sound scientific basis or evidence to support it. Indeed, there is evidence from studies in animals suggesting that these medications might be rather protective against serious lung complications in patients with COVID-19 infection, but to date there is no data in humans. The Council on Hypertension strongly recommend that physicians and patients should continue treatment with their usual anti-hypertensive therapy because there is no clinical or scientific evidence to suggest that treatment with ACEi or ARBs should be discontinued because of the Covid-19 infection.” (ESC)
Should afib patients self-isolate?
Because of the facts above, we believe that those with afib who are age 60 or more and/or who have other chronic conditions should be in self-isolation due to their increased risk.
During quarantine, most elective procedures, including catheter ablations and surgical ablations, were postponed for both the health and safety of the patient and to provide sufficient capacity for hospitals to handle an increase in coronavirus patients. However, as stay-at-home rules loosen, elective procedures are being resumed.
What does this mean for the Afib Patient Conference this year?
Your health and safety are of primary importance to us, and we don’t want to take any chances. Out of concern that we may not be completely through this coronavirus situation and clear to travel safely by this summer, we’ve pushed the Get in Rhythm. Stay in Rhythm.® Atrial Fibrillation Patient Conference to the fall.
This year’s conference will now take place Friday through Sunday, October 30 through November 1. All the other details of the conference will remain the same. We will post the faculty once we know who can make it on those dates.
Learn more at https://getinrhythm.com/