On Preventive Strategies

It is a well-known finding from all the major studies on COVID-19 from several countries including India that the highest risk of mortality is in populations more than 60 years of age (3.6%) and is incremental with age.14.8% for population more than 80 years of age. This is basically not because of ageing but due to associated medical problems with increasing age. Patients with high blood pressure (6.5%), diabetes (8%) and previous cardiovascular diseases (like old heart attacks, previous bypass surgery or angioplasty, angina etc) 10.5%.

Is the Risk of getting infection higher in these patients?

Patients with these problems are not at a high risk of getting infected as compared to general population but if they get infected by the virus the disease can take a more serious form. This is because of lower immunity related to more virulent viral entry into the cells. Lower viral clearance, diminished T cell function and more chances of severe inflammation leading to a Cytokine storm.

The key therefore is to be very vigilant. Maintain physical distancing, washing of hands with soap and water for more than 20 seconds, staying inside home as far as possible and use simple surgical or cloth masks if going out if necessary.

Preventive Steps for patients with high blood pressure:

To continue all the prescribed medicines including ACE inhibitors (Ramipril, Lisinopril, Enalapril etc) and ARB’s (Telmisartan, Losartan, Olmesartan etc). All other classes of drugs for reducing the BP are equally safe.

To keep BP under control by measuring it regularly. The usual recommended cut off as per our Indian guidelines is less than 140/90 mms Hg. Home BP measurement has been shown to be superior to an isolated BP recording in a clinic or doctor’s chamber. For this a calibrated and certified instrument available with chemists or on line is the best. In case the BP readings are concerning, it is good to communicate with your health care provider. Self-treatment is not recommended except for minor adjustments. Mercury manometers for BP monitoring have been phased out internationally. Oscilloscopic instruments rather than the dial type of aneroid instruments are preferred. They are easier to use and do not need a stethoscope etc.

The measures like regular physical activities need to continue for at least 30 minutes a day. It can be in the form of walking on the terrace or in the room, treadmill or stationary bicycle. It should come to about 8000 steps on your mobile or watch app. This also brings in a state of wellbeing.

Salt restriction, and eating low calorie diet with plenty of fresh fruits and vegetables is important to prevent weight gain.

Care for a Diabetic Patient

Besides observing all the general precautions as for patients with high BP, these individuals should control their diabetes well under supervision of their doctor. Blood sugar monitoring periodically by home devices which all diabetics should have. The sugar levels should be maintained between 70 to 180mgs, HbA1c below 7 %. Avoid hypo-glycemia.

Patients who get COVID +ve even without any symptoms like fever and cough need to get in touch with your doctor. Some drugs may have to be stopped. In general metformin and sulfonyl-ureas (Glimiperide, glibenclamide, Gliclazide etc are reasonably safe. However drugs like DPP4 inhibitors (gliptin group of drugs: linagliptin, sitagliptin etc ), Thiazolidinediones ( pioglitazone, rosiglitazone etc), GLPi analogues (Liraglutide etc) are avoided as far as possible because of the theoretical possibility of increasing viral loads. SGLT2 inhibitors (empagliflozin, dapagliflozin, canagliflozin) are reasonably safe unless there is high fever, vomiting etc. Insulin is very safe and all diabetics who need hospitalization with COVID are usually shifted to it. Any changes are to be made in consultation with your doctor.

Life style measures like exercise, low fat diet rich in fresh vegetables and seasonal fruits which are not very high sugar containing are recommended. Meditation like Prana yams and Yoga are good accompaniments.

Care of a patient with heart disease

Besides the routine preventive steps since this group is at the highest risk of serious events in case of infection extreme caution is needed.

All the drugs including aspirin, cholesterol lowering medicines and drugs to improve heart function like ACE inhibitors (Ramipril etc )and ARB’s (Losartan , valsartan etc), ARNI ( Sacubitril , valsartan combination etc), Beta blockers (metoprolol, bisoprolol etc) diuretics (Furosemide etc) must continue. The vaccination for flu (every year) and pneumonia (every 4 years) must be taken periodically.

If these patients become COVID +ve without symptoms none of the drugs should be stopped on their own but a consultation with the treating cardiologist should be sought. Since there is an overlap of some of the symptoms of cardiac illness with COVID like cough, shortness of breath and chest discomfort an expert opinion and early investigations are necessary which may require hospitalization in an appropriate hospital which will manage and also repeat a COVID test if needed.

Acute symptoms of chest pain, shortness of breath or fainting need attention at the earliest. The management of a heart attack and related life-threatening problems is an acute emergency and needs an urgent attention at the closest hospital with facility for treating heart patients. Don’t waste time and go early.

It is important to remember that the mortalities of treatable diseases should not increase while trying to contain COVID infections. There is a general impression that a smaller number of patients with acute heart emergencies are presenting to hospitals since the beginning of the lock down. This defies science and may lead to a sudden up rise with major complications due to delayed treatment after curbs are eased out.

Author is a Cardiologist, Past President of Cardiological Society of India and SAARC Cardiac Society, Editor in Chief of ASIAINTERVENTIONS, a recipient of Padmashiri and Dr B C Roy Award.