February 2021 Vol.8, No.1

Inside this issue:

Long-term effects 3

1

Health Disparities 4 Special COVID-19 Update Edition

On the Front Lines 10 Drs. Grossman and Long

Happy New Year and welcome to the first edition ofYour Healthy Heart in 2021. This free community newsletter is published by the Center for Prevention of Heart and Vascular Disease, a part of UCSF Medical Center’s Cardiology Care Clinic and the UCSF Division of Cardiology.

Clearly 2020 was an unprecedented year in so many ways from COVID-19 to devastating wildfires to racial injustice. We are medical doctors Bill Grossman and Carlin Long, co-directors of the Center for Prevention, and want to acknowledge the hardship, loss and sacrifice that so many made in the past year. We are deeply grateful for all who sacrificed their time, effort and expertise to assist others, especially frontline service providers and first responders, other essential workers and civic activists, fire-fighters and all caregivers. We’ve all witnessed true heroism in the face of unimaginable adversity and owe enormous debts of gratitude to others in our families and our communities.

Our objective for Your Healthy Heart remains the same: to provide practical, science-based healthcare information to deepen understanding of various medical conditions, treatments and research and (hopefully) to spark rich dialogue with peers and healthcare providers. In light of last year’s events, we have chosen to stray from our usual content and dedicate this edition to COVID-19. Some articles exclusively address issues of the virus and it’s medical and socio-economic ramifications while others deal with COVID-19 and cardiovascular disease.

Several of our fellow cardiology colleagues have contributed to this edition. Michelle Albert, MD, MPH (Page 4) looks at the disparate impact COVID-19 is having on members of the African American community. Nisha Parikh, MD, MPH (Page 6) shares how we have 2 quickly adapted our practices to safely care for patients during the pandemic. And Ethan Weiss, MD (Page 10) offers a first hand account of working in the ICU of a hard hit New York City hospital. Given the special nature of this issue, our regular features such as Dr. Long’s Research In The News and Dr. Grossman’s Ask Dr. Grossman have been omitted and will return in our next edition.

We want to again thank you for your ongoing support of our Prevention Center. More than ever, we remain committed to caring for our patients by leveraging clinical expertise and the best therapies to provide world-class care. We welcome your feedback about this publication or our website at www.healthyheart.ucsf.edu. Email your comments to: [email protected].

Warmest regards,

Carlin Long, MD Director, Center for Prevention of Heart & Vascular Disease Professor of Medicine, University of California, San Francisco

William Grossman, MD Charles and Helen Schwab Endowed Chair in Preventive Cardiology Co-Director, Center for Prevention of Heart & Vascular Disease Professor of Medicine, University of California, San Francisco Clinical Update: Discovering the Long-Term Effects of COVID

Interview of Liviu Klein, MD, MS

“COVID can impact the heart in two main ways,” said Liviu Klein, MD, Learning Over Time MS, director of the UCSF Mechanical Circulatory Support program and an expert in advanced heart failure and cardiac transplantation. Similarly, another study based in Europe studied 1,200 COVID patients with an average age of 60. “Half of the patients had First, some patients may develop heart disease when they initially abnormal echocardiograms, but less than 10 percent of the patients present with COVID-19. This could include myocarditis, which is had clinical manifestations of heart disease, such as a heart attack, inflammation of the heart muscle; or vasculitis, which is inflammation cardiomyopathy or myocarditis,” said Dr. Klein. “The bottom line of the blood vessels feeding the heart muscle. These conditions from both these studies is that these patients need to be followed could progress to cardiomyopathy, or weakening of the heart muscle, long-term with repeated studies of the heart. Right now we don’t and in rare cases, full-blown cardiogenic shock – a condition in which know if that’s for six months, a year, two years, or more.” the heart is suddenly unable to pump enough blood. Other patients may develop abnormal heart rhythms like atrial fibrillation. These sorts of silent effects are not limited to the heart. “There are elegant studies looking at the lungs of COVID patients who tested Second, cardiologists are just starting to learn how some COVID-19 positive but had no symptoms,” said Dr. Klein. “A randomly selected patients may experience chronic effects on the heart even after they sample received CT (computed tomography) scans of the lungs, have recovered from the virus. For example, a recently published and surprisingly, those patients actually showed lung damage.” German study followed about 100 patients whose average age was 50. Most had recovered from COVID after experiencing mild So much remains to be learned about the long-term impact of to moderate symptoms of the disease, and only a few had required COVID-19. “The vast majority of patients infected with COVID 3 intensive care. Two months after their initial COVID-19 diagnosis, all don’t have a clinical presentation, and we don’t know their cardiac of them underwent cardiac magnetic resonance imaging (MRI), a very involvement,” said Dr. Klein. “In people who are symptomatic, most detailed test which can reveal information not detectable with other of them have mild to moderate symptoms and can recover at home. types of imaging. What’s worrisome is the long-term consequences, which seem to be quite serious for patients who recover from this infection. That’s “By all measures, most of the patients were perceived to be low-risk,” where we as cardiologists will need to do a lot of work in the future.” said Dr. Klein. “Some patients had high blood pressure, diabetes or coronary disease, but most didn’t have any heart disease risk factors. As troubling as this is, Dr. Klein is still hopeful. “There are probably So it was quite surprising that about 80 percent had abnormal over 100 clinical trials in progress throughout the world, and it’s findings on their cardiac MRIs.” interesting how this disease has mobilized resources, academia, industry, and regulatory bodies,” he said. Those abnormalities included inflammation, or inflammation plus “COVID-19 has created a lot of tragedy scarring – which meant that part of their heart muscle was essentially and mortality, but at the beginning of the dead, presumably from their COVID-19 infection. Some of the year we didn’t even know that this virus patients with inflammation or scarring also underwent heart biopsies, existed, and now we have five companies which confirmed that the patients had active inflammation. with vaccines. The amount of progress in therapeutics, diagnostic testing, “How are we as cardiologists going to follow these patients over the and treatment, and how fast long-term?” asked Dr. Klein. “It shows that even though they made these have been tested in it through the acute event of having COVID-19, they may not be clinical trials, is just out of the woods.” unprecedented.”

Liviu Klein, MD, MS COVID-19 and Health Disparities

A discussion with Michelle Albert, MD, MPH

The COVID-19 pandemic has revealed some of the deepest Socioeconomic factors play a large role. For example, many fault lines in our society, taking a disproportionate toll on African Americans and Hispanics are essential workers who African Americans, Native Americans and Latinos. UCSF take public transportation to their jobs in the food and service cardiologist Michelle Albert, MD, MPH is at the forefront of industries. Many live and work in crowded environments where investigating these health disparities and ways to address it is impossible to physically distance from others. Many also them. face obstacles to accessing health care.

While these groups have higher rates of risk factors such as Dr. Albert serves as president of the Association of Black hypertension, diabetes, and kidney disease, that is only part of Cardiologists, and she and her colleagues at that organization the story. “We know that about 80 percent of health relates to recently published a paper in Circulation proposing solutions social factors, and only about 20 percent to genetics,” said Dr. to reduce health disparities: expanding health coverage and Albert, director of the CeNter for the StUdy of AdveRsiTy and access to COVID-19 testing, providing dorm and hotel rooms CardiovascUlaR DiseasE (NURTURE Center) and associate to people who need to quarantine, providing food for those dean of admissions for the UCSF School of Medicine. “We in need, and providing safe transportation options, among have two pandemics occurring: a pandemic of racism, and the others. COVID-19 pandemic on top of that.” Black Women and COVID-19

4 For example, African Americans accounted for 70 percent of COVID-19 fatalities in Louisiana last spring, while comprising Dr. Albert was recently awarded an American Heart only 32 percent of the population. Similarly, frontline health Association (AHA) rapid response grant to study care workers of color in the U.S. and the United Kingdom were cardiovascular complications and mortality in Black women almost twice as likely as their white colleagues to test positive who have been affected by COVID-19. Her team was one for COVID-19. of only 10 to receive funding from this highly competitive program, which received 750 applications. Her group includes the UCSF NURTURE Center and collaborators at Boston University, which has enrolled 15,000 participants in its questionnaire-based Black Women’s Health Study.

Dr. Albert and her collaborators will seek to identify risk factors and outcomes related to COVID-19, and to develop targeted interventions. “One question we have is whether there are

Michelle Albert, MD, MPH unique things that pop up among Black women that get lost The pandemic has hit close to home: Dr. Albert’s own mother in other studies, where Black women represent only a small was hospitalized for three weeks with COVID-19. “I knew if percentage of the study,” said Dr. Albert. She hopes to secure we called an ambulance, they would take her to the nearest additional funding to understand the longitudinal effects of hospital to her residence and she wouldn’t survive,” she said. COVID-19. “I told my cousins to put her in a car and drive her as fast as they could to a hospital where I knew that she would get “Black women are at the intersection of the worst economic great care and have a chance at survival. Social vulnerability and health disparities that exist,” said Dr. Albert. “They’re the includes which hospital you present at. Just because I’m a fulcrum of the community, and tend to be caregivers not only cardiologist, my family and I are not immune to the effects of of children, but also of elderly relatives. They are also more racism-based health and economic disparities.” frequently household breadwinners compared to women of other racial or ethnic groups, and are more likely to live in The AHA recently awarded her the prestigious Population disadvantaged neighborhoods and households, regardless Research Prize in recognition of her outstanding research of education or income level. Even in circumstances where endeavors using epidemiology and population science. “I Blacks are highly educated, the returns gotten on that want to improve the lives of populations which are at greatest investment are substantially less than for their white peers.” need,” said Dr. Albert.

5 Protecting Health, Sharing Information

A discussion with Nisha Parikh, MD, MPH

At the beginning of 2020, hardly anyone had heard of include cardiovascular biomarkers like troponin, which can COVID-19. As this devastating disease quickly swept across indicate possible heart damage and could indicate a worse the globe, clinicians scrambled to learn how best to treat it and prognosis. For patients with mild to moderate COVID-19, the prevent its spread. evidence suggests that there is no clinical benefit to taking patients off angiotensin-converting enzyme (ACE) inhibitors or In the UCSF Division of Cardiology, Nisha Parikh, MD, MPH, angiotensin receptor blockers (ARBs). has led the development of clinical guidelines to provide the very best care, and to keep patients, doctors and staff as safe Because COVID-19 can have a particularly harmful effect as possible. “We really came together as a group to develop on the lungs, cardiologists have learned that the disease protocols for how to interact with patients safely in the clinic, can contribute to right ventricular dysfunction – since this echocardiography lab, cardiac catheterization lab, and cardiac chamber of the heart is the one that pumps blood to the lungs. intensive care unit (ICU),” she said. “Of course, much of this is They also monitor for hypercoagulability, or excessive blood a moving target, and we’ve learned a lot about the disease.” clotting, since COVID-19 can also contribute to this disorder. She and her colleagues have posted these evolving guidelines “A lot of what we put together was based on conversations online (bit.ly/covidcardio) as a resource for other institutions as with frontline colleagues from ‘hotspots’ around the country,” they develop their own guidelines. said Dr. Parikh. “Keeping those lines of communication open is very important, and will get us all through this.”

6 In Cardiology, one of the highest-risk procedures for COVID-19 transmission is a transesophageal echocardiogram (TEE), in which a cardiologist inserts a probe into a patient’s mouth and down the esophagus in order to provide a detailed look at the heart. “TEEs can be aerosol-producing procedures,” said Dr. Parikh. “So even if a patient tested negative for COVID, we assume that they could have it, and have our team wear N95 masks and full face shields.”

Dr. Parikh also worked with Jamie Kennedy, MD, medical director of the cardiac ICU, Benjamin Kelemen, MD, a cardiology fellow, and others to develop a list of recommended lab tests that could help assess cardiac dysfunction. These

Nisha Parikh, MD, MPH Don’t Delay Care Her co-presenters included UCSF cardiologists Bruce Conklin, MD, and Krishan Soni, MD, MBA; UCSF cardiology fellows Perhaps the most important message for patients is to seek Joseph Bayne, MD, Dr. Kelemen, and Gregory Judson, MD; prompt treatment for urgent symptoms. “At the beginning of and guest presenter Daniel Sims, MD, medical director of the the pandemic, there was some confusing messaging about Montefiore Medical Center cardiac ICU in the Bronx. when to come in, but now the air has cleared,” said Dr. Parikh. “We’ve been doing this for a while, and we have a good sense “At UCSF, we are very lucky to have access to all sorts of of how to be safe in clinic. Please don’t ignore chest pain or town halls and grand rounds presented by world leaders,” shortness of breath. We definitely want patients to be seen said Dr. Parikh. “We in turn distilled all that great information for their heart symptoms, so we can prevent any long-term and provide it to our community partners. These forums problems from developing.” are attended by hundreds of people, and everyone is so appreciative. It’s really heartwarming to see the ways that In addition to developing clinical guidelines, Dr. Parikh has this pandemic is bringing everyone together. There’s been so coordinated a series of grand rounds and educational sessions much great teamwork, from putting together these educational for the community, including One Medical Group, community activities to developing clinical guidelines. We’re all learning cardiovascular disease referral partners, and statewide from each other.” associations of nurse practitioners and physician assistants. 7 COVID-19 Citizen Scientist Study

Interview of Gregory Marcus, MD

It often takes years to recruit and enroll participants in clinical “To my knowledge, the study is unique because we’re research – a true challenge with a fast-moving pandemic. following individuals prospectively over time, and have collected very rich information regarding their baseline Luckily, several years ago the UCSF Division of Cardiology characteristics, as well as time-updated information about developed the Eureka research platform to conduct the Health their behaviors, exposures and risk factors,” said Dr. Marcus. eHeart Study. Funded by the National Institutes of Health For instance, they collect information weekly about sleep, (NIH), Eureka has enabled more than 300,000 participants to exercise, alcohol consumption and employment status. use their digital devices to answer questionnaires and share information like daily step counts, allowing investigators to use The study has enrolled more than 37,000 people, including big data to discover more about heart disease. participants from every state, 93 countries, and six continents. So far, at least 96 percent of participants have filled out at In March, the research team quickly adapted Eureka to study least one survey per week. Participants can also submit the coronavirus. “Using Eureka to power the COVID-19 Citizen their own questions, and the team selects some of these for Scientist Study, we thought we might be uniquely positioned inclusion in the monthly surveys. to identify individual exposure levels as well as protective or risky behaviors,” said Gregory Marcus, MD, Endowed They have already made some intriguing discoveries. “When Professor of Atrial Fibrillation and associate chief of research we started analyzing our geolocation data, our statistician for the UCSF Division of Cardiology. said, ‘This doesn’t look right – someone was in two different 8

He and his co-principal investigators – Jeffrey Olgin, MD, chief of the UCSF Division of Cardiology and Ernest Gallo-Kanu Chatterjee Distinguished Professor in Clinical Cardiology, and internist and epidemiologist Mark Pletcher, MD, MPH – pivoted with remarkable speed. Within two weeks, they developed the intake questionnaire, as well as daily, weekly and monthly surveys, and ways for participants to donate geolocation and daily step count information. The UCSF Institutional Review Board approved the study in two days.

“We designed the study to be deliberately nimble,” said Dr. Marcus. For example, when other researchers discovered that loss of taste or smell could be associated with COVID-19, the team added these symptoms to the questionnaires. As public health guidance evolved, they began asking participants what percentage of the people they interacted with wore masks or were behind barriers.

Gregory Marcus, MD locations within 24 hours that are 3,000 kilometers apart,’” will use the Eureka infrastructure to do head-to-head said Dr. Marcus. “Then we realized we can infer long-distance comparisons between the current gold standard test and flights from geolocation data…. We can also determine their the many new COVID-19 tests that provide results within most commonly reported location, which we assume is home, a few hours. The results will help the U.S. Food and Drug and can objectively quantify how often they’re actually there, Administration decide which tests to approve. and how much they travel.” With additional funding, Dr. Marcus and his collaborators The study has garnered interest from other investigators, would love to actively recruit more participants, partner public health departments, and funders. The group was with testing centers nationally to test large numbers of recently awarded funding from the Bill and Melinda Gates participants, and perhaps even provide a service that Foundation and the Patient-Centered Outcomes Research could notify participants if they have crossed paths with Institute to enroll large numbers of participants and invite them someone who later tested positive. “Philanthropy is the best to contribute additional information, such as electronic health mechanism to promote innovation,” he said. “We achieve record data. The NIH is funding them to become a platform for the most success when we’re free to pursue the most numerous COVID-19 sub-studies led by other investigators. novel ideas, and can quickly adapt to a rapidly changing landscape.” They also received another NIH grant as part of a multi-center collaboration to evaluate point-of-care tests. This initiative 9 On the Front Lines in New York

Closeup from inside a COVID Emergency Ward with Ethan Weiss, MD

In mid-April, cardiologist Ethan Weiss, MD, learned that One patient was intubated for almost the entire time Dr. UCSF clinicians were traveling to New York to take care of Weiss cared for him. “Even when he was extubated for a few COVID-19 patients. “I was proud of them, but also thought, hours, he was like a ghost,” he said. “These patients were ‘I want to do that!’” he recalled. Two weeks later, he was debilitated and malnourished, and their muscles were so on his way to NewYork-Presbyterian/Weill Cornell Medical weak that they couldn’t even make facial expressions. It was Center in Manhattan. awful. Then a couple weeks later, I got an amazing email from that patient, thanking me for not giving up on him.” “I was both scared and curious,” said Dr. Weiss. “I wasn’t that afraid of getting sick myself, but more worried I Other stories were more wrenching. He cared for a patient wouldn’t be helpful.” The hospital had hundreds of patients whose only living relative was her brother, who was also with COVID-19, many of them requiring intensive care and hospitalized with COVID-19. “Their parents had died, and intubation. The first week, he took care of nine COVID they were each other’s everything,” said Dr. Weiss. “They patients in a makeshift ICU which had formerly been a lived together and took care of each other. They came to cardiac step-down unit. Their average length of stay was the hospital the same day. She ended up in the ICU, and he about 45 days. The second week, he cared for another nine went to the regular floor. They never saw each other again. patients who were even sicker, some with severe cardiac He was distraught because his sister was dying, but was and clotting-related problems.

10 “This is a terrible disease,” said Dr. Weiss. “Their lungs were absolutely devastated. There was a lot of trial- and-error medicine at that time, with debate about what therapies worked. We didn’t have time to wait for a clinical trial, and we tried to make thoughtful decisions.” His patients ranged from their 30s to their 70s. Many were obese or had diabetes, but some had been completely healthy before they became infected.

“COVID is so different from anything we’ve ever seen,” he said. “The course of this illness is a metaphor for the pandemic itself: it comes on like a tornado, but will creep away over months or years like a slug. One of the main things I learned is that some people I would have given very little hope of recovering actually did recover.”

Ethan Weiss, MD also imagining a life of loneliness that he was going to be “COVID-19 is really serious, and you don’t want to get living going forward, while also trying to get better from it,” said Dr. Weiss. “We should all take reasonable steps COVID-19. It was one of the most emotionally charged to protect each other by maintaining social distance experiences I’ve ever had as a physician.” and wearing masks. At the same time, if we take the appropriate cautions, we can have some semblance of Through this intense experience, Dr. Weiss was inspired a normal life. I think San Franciscans – both our political by his colleagues. “I was so tired, but the health care leaders and the community – should be commended for providers there had been doing this nonstop for over six doing a great job of taking this seriously. I think we’re going weeks, and they just kept coming back with more energy to be living with this for a very long time.” and resilience,” he said. “It was medicine in its purest sense, where everyone was entirely focused on, how can we best take care of the patient in front of us? It was the strongest experience of collective good that I’ve ever been part of.”

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Heart Healthy Strategies Education Series

View UCSF Department of Medicine Grand Rounds discussions of COVID-19 related news, research and public health policy featuring leading local, national and international experts. https://medicine.ucsf.edu/covid-19-news-coverage

Your Healthy Heart is published by the Center for Prevention of Heart and Vascular Disease at the University of California, San Francisco | www.healthyheart.ucsf.edu For mailing list corrections, additions, or to be removed from the list please send an email to [email protected] Contributors: Michelle Albert, MD, MPH; William Grossman, MD; Liviu Klein, MD, MS; Carlin Long, MD; Gregory M. Marcus, MD, MAS; Nisha Parikh, MD, MPH; Ethan Weiss, MD. Producer: Marc Vincent, MA. Graphic Design: Niana Liu. Photography: iStock Photo. Content reprinted with permission from UCSF’s Heartline (2020).