COVID-19 Emerging as a Multi-Organ Disease Requiring Multidisciplinary Care

LONG-TERM PULMONARY AND CARDIAC SEQUELAE

Pulmonary sequelae include decreased exercise capacity and hypoxia. Long-haulers have been found to have reduced diffusion capacity, restrictive pulmonary physiology, and ground-glass opacities and fibrotic changes on imaging, according to the researchers.  Palpitations, dyspnea and chest pain, increased cardiometabolic demand, myocardial fibrosis, scarring arrhythmias, tachycardia, and autonomic dysfunction are associated with cardiovascular sequelae.

Data suggest that patients with cardiovascular complications during acute infection and those experiencing persistent cardiac symptoms may need to be monitored, Wan et al. They write that mechanisms perpetuating cardiovascular sequelae in post-acute COVID-19 include direct viral invasion, downregulation of ACE2, inflammation and the immunologic response affecting the structural integrity of the myocardium, pericardium and conduction system.

A reduced eGFR has been reported at 6 months follow-up and there is concern about persistent impaired renal function. “Follow-up of renal function should be incorporated in care provided in COVID-19 recovery clinics, with engagement of nephrologists for those with impaired renal function. Approximately one-third of patients with COVID-19 had reduction in estimated glomerular filtration rate at 6 months follow-up in a study from China, including some with normal renal function during acute infection with SARS-CoV-2,” Dr Sehgal said.

THE NEXT BIG HEALTH CRISIS

The World Health Organization estimates that 10% of COVID-19 survivors will develop long-term healthcare issues. To date, here in the United States, 31.4 million people have contracted COVID-19, with estimates suggesting that 3 million people in the US could potentially develop long-term health conditions associated with COVID-19.

“These people need integrated multidisciplinary holistic care. Health systems should quickly adapt to this reality. It is not an exaggeration that long COVID is America’s next big health crisis. We should prepare for it now,” said Ziyad Al-Aly, MD, an internal medicine specialist with the Institute for Public Health in Washington, DC.

Due to the fact that COVID-19 in both the acute phase (first 4 weeks) and post-acute phase affects the lungs, heart and kidneys, some specialties have had to rise to the challenge and adapt quickly to treat COVID-19 patients, he said.

“I think that many specialties, including nephrology and cardiology, still underestimate the tide of patients with post-COVID sequelae that will likely need medical care in the next one to five years,” Dr Al-Aly said. He is working on a study to systematically characterize the post-acute manifestations of long-haulers.

It is clear that most long-haulers do not realize they have heart damage, kidney damage or liver damage because they are not experiencing symptoms. “At some point, these patients will need medical care. Health systems and specialties must be prepared for this,” he said. “If there ever was an exemplar in clinical medicine that best captures the importance of integrated multidisciplinary care, it is long-haul COVID-19. It is staring at us in the eyes,” Dr Al-Aly said.

Dr. Sehgal and his colleagues contend that clinical trials of patients with COVID-19 presenting with new long-term medical complications are urgently needed. “Active and future clinical studies, including prospective cohorts and clinical trials, along with frequent review of emerging evidence by working groups and task forces, are paramount to developing a robust knowledge database and informing clinical practice in this area,” the authors wrote. 

References

1. Cortinovis M, Perico N, Remuzzi G. Long-term follow-up of recovered patients with COVID-19. Lancet. 2021;397:173-175. doi:10.1016/S0140-6736(21)00039-8
2. Nalbandian A, Sehgal K, Gupta A, et al. Post-acute COVID-19 syndrome. Nature Med. 2021;27:601-615. doi:10.1038/s41591-021-01283-z