Updated on 4/22/20
On March 18, Peggy Peck, BreakingMED Editor-in-Chief, conducted a video interview with Clyde W. Yancy, MD, Vice Dean for Diversity and Inclusion Chief of Cardiology in the Department of Medicine, Feinberg School of Medicine at Northwestern University in Chicago, to discuss special considerations for heart failure patients in the midst of the Covid-19 pandemic. BreakingMED followed up with Yancy and asked him to reply to a series of emailed questions. The answers to those questions are below, followed by the original video interview and a full transcript of that interview.
What new challenges have you experienced over the last several weeks?
Clyde W. Yancy, MD: The evidence of striking health disparities has given many of us pause. This is a quote from a viewpoint I wrote for JAMA: “A 6-fold increase in the rate of death for African Americans due to a now ubiquitous virus should be deemed unconscionable.
“This is a moment of ethical reckoning. The scourge of Covid-19 will end, but health care disparities will persist. Does the U.S. chronicle these poor outcomes due to Covid-19 complications with the higher burden of cardiovascular disease, poorer outcomes for breast cancer, higher amputation rates for peripheral vascular disease, lower kidney transplant rates, and worse rates for maternal mortality, then safely park everything in the health care disparity domain and go back to ’normal’? Or will the nation finally hear this familiar refrain, think differently, and as has been done in response to other major diseases, declare that a civil society will no longer accept disproportionate suffering?”
Have you had adequate access to PPE?
Clyde W. Yancy, MD: Yes, I applaud our hospital leadership for the ability to source PPE and provide protection for our teams; the collaboration between the hospital leadership and physician leadership has been exemplary.
I have a few questions about testing: Is there adequate testing available in your community?
Clyde W. Yancy, MD: Testing remains a challenge.
I am optimistic that science and technology will fully address this need. Sourcing faster testing platforms and developing effective screens for antibody presence are goals that we are working on at our center. Ubiquitous testing will be needed to fully re-engage with life; we will need some certainty about exposure and the ability to quarantine. I’ve not seen the medical community respond with such force, (politics not withstanding), and my sense is that we will bring forward new technology soon.
Are you enrolling patients in any of the FDA-approved clinical trials?
Clyde W. Yancy, MD: Yes.
I am chair of the DSMB for the HERO HCQ trial — a 15,000-person, healthcare worker RCT randomized to hydroxychloroquine [HCQ] versus placebo. The goal is to use HCQ as prophylaxis against Covid-19 infection.
Our center has completed enrollment in one of the remdesivir trials and we are quickly moving forward with the national AHA Covid-19 Registry built on our [Get With the Guidelines] platforms (with which I have 15 years of experience so I am pleased to see this come to fruition).
Finally, do you have any additional thoughts or comments to share?
Clyde W. Yancy, MD: I’m exhausted by the stress; disheartened by the toll on human life; concerned deeply about the exposure to healthcare workers- BUT, I am emboldened by the display of courage, selflessness, compassion, and sacrifice that I see in physicians, nurses and health care workers across the country.
Responding to the Covid-19 crisis is at the core of what incited many of us to become a doctor- to serve others. At a time like this, to see character leading the way is remarkable.
Peggy Peck: What are you telling your heart failure patients with regards to Covid-19?
Clyde W. Yancy, MD: This is really a great conversation for us to have because there are some explicit questions that have emerged, and we really need to communicate the best possible information we have based on what’s known in the public domain.
The first thing is that we’ve been very intentional. We have advised patients with heart failure to heed the messages about those persons deemed to be at risk. We believe that underlying cardiovascular disease along with advanced age, but particularly when the two are together, really does represent that group that may be at even higher risk, higher risk for the complications of Covid-19 up to and including mortality. This is to be taken very seriously.
So, yes, we hear the public health messages for older persons, those over the age of 60, but we are particularly emphasizing that message for persons we know who have concomitant heart failure.
That’s the first thing that we’re telling everyone, so much so that we’ve created a narrative that we are distributing to patients as they call in, so the same message is getting to everyone to understand our conviction that we believe this is one of the most important things that the person with heart failure can to do to preserve their health in today’s crisis environment that we’re experiencing.
There is a second issue that I think is very important, and again, we’ve created a narrative to be very direct in addressing a number of questions that have arisen through social media. I really do think social media provides an excellent resource and has been very valuable here by giving us some very timely frontline perspective on what’s going on. But there also has been this eruption of conversation dialogue about the potential harm or benefits of the use or withdrawal of ACE inhibitors or ARBs.
We want to be very careful with this.
There isn’t sufficient evidence to say that someone either should initiate ACE inhibitors or ARBs or discontinue therapy if taking in the space in this domain of being exposed to Covid-19. It is correct that the severe, acute respiratory syndrome viruses do enter the cell via the angiotensin-converting enzyme-2 receptor.
It’s very different than what we think about in clinical cardiovascular medicine, but nevertheless, people have conflated that biology with use of ACE inhibitors and ARBs.
We need a lot more data to understand whether there’s a real risk, but we do know this: in patients with compensated heart failure who abruptly discontinue guideline-directed medical therapy, that’s never a good thing. And for a patient to concomitantly develop an exacerbation of heart failure in today’s environment would be very much an unwise decision.
So, we would suggest yes, there are questions, there is no data to provide a direction and what’s most important is to avoid the inappropriate discontinuation of evidence-based therapy whether it’s for hypertension or for heart failure.
That’s really important.
Peggy Peck: And I’m just wondering, do we have any sense of any role or any concern about ARNI therapy?
Clyde W. Yancy, MD: The question about ARNI therapy is an appropriate extension of what we’re talking about.
To the extent that the ARNI compound includes an angiotensin receptor antagonist the very same narrative applies. If you’re on an ARNI appropriately, and you should be on it only for appropriate reasons, stay with the therapy.
It’s a more intriguing conversation about a neprilysin inhibitor and whether that might have some risk or some benefits in this setting, thinking about cardiopulmonary protection or exacerbation. We simply don’t know, but the overarching statement to make to everyone: if you are taking these evidence-based drugs for appropriate indications stay with your therapies.
Do not yield to this initiative that’s brewing that says that some of these therapies may be harmful. There is no evidence to support that.
There are questions, but no evidence to support that.
Peggy Peck: And then just one other thing, you practice. You’re at Northwestern and Feinberg. You’re in a large metropolitan area, and we’ve heard some concerns about healthcare workers there and stress on the system. Just give me your perspective from this as, you know, this is your hometown look, so to speak.
Clyde W. Yancy, MD: You know, I really can’t commend you enough for bringing up the personal side of this.
We, as physicians, are trained to respond. Respond in the setting of emergency. We are, in fact, inclined to sometimes ignore our own risks.
Why do we work the long hours we do?
Why do we take the risk with high-risk patients like we do in a day in, day out basis?
This is a very different environment.
We have to understand that we as healthcare workers are uniquely at risk. We don’t understand exactly how to avoid the risk. We have to be very judicious with personal protection equipment, and we have to remember that as humans we are vulnerable.
Many of us are over the age of 60. Some of us may have concomitant disease.
The short version is that if we are to deliver the care we’ve been trained to deliver and to do that in a compassionate, effective way, we have to maintain our own health.
We are developing rotating schedules, so we always have a healthy workforce available. We are advocating the aggressive and assiduous use of handwashing and personal protection equipment. This is important for the near term, but also when this settles—and it will settle—there will be many people with chronic conditions that perhaps didn’t receive prompt attention or those that are surviving Covid-19 and we have no idea what the longitudinal consequences of that might be. We will need an intact, healthy workforce.
And there’s one other piece.
Don’t forget the toll this takes on us emotionally. Many of us, particularly in cardiology, are trained to really hold tight and be rigid and firm and to deal with circumstances when we face them, but this has an emotional toll.
Just this morning we’ve been distributing techniques, strategies, call it psychological first aid, ways to cope with this condition, ways to cope with what we may witness over the next several weeks.
So, very appropriate question to bring up something that we’re having to manage real-time.
Peggy Peck: Thank you, Dr. Yancy. You’ve been very, very generous with your time, and of course very helpful as usual. Thanks again.
Peggy Peck, Editor-in-Chief, BreakingMED™
Cat ID: 190
Topic ID: 79,190,791,3,190,926,255,927,151,928,195,929,925,934