The Skeptical Cardiologist Coronavirus Scorecard: ACE inhibitors, Awking, and Afib

A large part of what makes a good scientist as well as a good clinician is the ability to look back at your decisions, your medical/scientific beliefs, your writing and your teaching, learn from the mistakes you have made and modify accordingly.

To that end, the skeptical cardiologist has started reviewing his posts on COVID-19 in light of what we now know after a year of the pandemic.

ACE2 and COVID-19

My first blog post on COVID-19 published 3/14/2020, sought to reassure patients and readers of the need to stay on an important class of cardiovascular medications despite widespread press and social media reports suggesting these drugs increased the risk of death from SARS-CoV2.

Many of my patients with hypertension and/or cardiovascular disease are taking drugs termed angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs.) Both types of drugs are mainstays in our treatment of hypertension and heart failure. Lisinopril and ramipril are common ACE inhibitors whereas valsartan, losartan, and irbesartan are common ARBs. Speculation that these drugs might be contributing to mortality associated with COVID-19 was initiated by a “Rapid Response” published online March 3 by the British Medical Journal in response to an editorial on “preventing a COVID-19 pandemic.” and “Correspondence” to the Lancet published March 7.

Two weeks later, I reiterated that advice in “An update on ACE2, RAAS, and COVID-19“.

In the last year, a multitude of studies have conclusively demonstrated no increased risk for any aspect of COVID-19 with this class of medications.

This TCTMD.com article summarizes nicely the arc of this issue over the last year that concludes with a meta-analysis showingthat RAAS inhibitors actually lowered the risk of death in patients with COVID-19.

“In the fully adjusted model … use of an ACE inhibitor/ARB was associated with a significantly lower of death in the overall cohort (OR 0.57; 95% CI 0.43-0.76), and this reduction was seen in patients with hypertension (OR 0.51; 95% CI 0.32-0.84) and in those with multiple comorbidities (OR 0.64; 95% CI 0.46-0.88).

I’m giving the skeptical cardiologist an A+ on this recommendation.

Remote Monitoring of Atrial Fibrillation

By March 18, 2020 I realized that with COVID-19 cases rapidly increasing physicians should be utilizing methods to remotely handle urgent cardiac problems whenever possible and I wrote a post entitled Atrial Fibrillation In The Time of Coronavirus: A Call For More Personal Remote ECG Monitoring:

Clearly, at this time everyone needs to minimize visits to the doctor’s office, emergency room, urgent care center or hospital. But patients with paroxysmal atrial fibrillation by definition will have periodic spells during which their heart goes out of rhythm and many of these will occur during this period when we want to minimize contact with individuals outside the home.

In that post I described in detail the methods we utilize for remote monitoring atrial fibrillation with personal ECG devices from Kardia or Apple Watch, concluding with “afib patients who do not have a method for self-monitoring their heart rhythms should consider acquiring a Kardia device or Apple Watch.”

In the pandemic year that followed, we were able to handle most episodes of atrial fibrillation utilizing these remote monitoring techniques combined with remote, rapid and responsive telehealth communication.

I still believe more widespread adoption of these technologies with or without on ongoing pandemic is needed and will significantly reduce ER visits and hospital admission for patients with atrial fibrillation

Score=A.

Walking Becomes Awking

By late March, COVID-19 was impacting our daily lives and I published a guest post from my former Eternal Fiancee’ on her COVID-19 neologism:

I’ve noticed a funny phenomenon. Because of the 6 feet distancing in effect, it’s getting more challenging for me to go on walks. I am constantly having to move to the other side of the street or the middle of the road to avoid people.

It’s incredibly awkward because I don’t want to offend anyone and make them feel like I think they are infected. But at the same time, I’m trying to follow the rules and protect myself.

She submitted this to the Urban Dictionary and now if you Google awking the #1 hit is her definition.

There are only 16 thumbs up but no thumbs down so I’ll give her a B+ for this.

I mentioned in that post that I had created a portmanteau word-farb. Reading the nutritional content of a snack bar I smashed fiber carbs into one word. Farbs are important to those on ketogenic diets as they don’t add to the total carb count.

However, if you google farb you won’t find my neologism. Wictionary defines farb as “A historical reenactor (especially an American Civil War reenactor) whose efforts at a historically accurate portrayal are, in the opinion of the speaker, inadequate (for example, wearing a modern wristwatch with period costume).”

One suggested source for this definition is the acronym of a phrase (“fallacious accoutrements & reprehensible baggage”) describing phony militar gear in a letter from a Civil War soldier.

For my contribution to this post, I’m assigning myself an F.

However, I have learned from this experience and am now eager to properly use the word farb if I ever witness a Civil War reenactment and to frequently trot out the phrase “fallacious accoutrement” (pronounced with my outrageous French accent) as a descriptor of the various accessories my former Eternal Fiancee typically wears during our neighborhood awking adventures.

Farbishly Yours,

-ACP

N.B. Clearly, this post covers only March of 2020 and I wrote a lot more COVID-19 related content. As the scorecard progresses I’ll review my posts on hydroxychloroquine, the Oura ring misinformation campaign, pulse oximeters and masks.

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2 thoughts on “The Skeptical Cardiologist Coronavirus Scorecard: ACE inhibitors, Awking, and Afib”

  1. About the personal devices: With the opportunity for long-term pretty continuous monitoring that these personal devices provide, I’ve been wondering if it would be possible to compute a paroxysmal afib burden number that might be useful for research, especially on the topic of how much burden is too much. For example, from my own records, I simply computed (total time in afib)/(total time) and got a few percent over the course of the last year or so. I have no idea what this means in terms of what treatments I should be considering. However, enough data of this sort might clarify the chances of success of an ablation as a function of burden, and under what conditions drugs cease to be effective. I have seen an older, somewhat small study, where longer-term monitoring showed afib burden was related to stroke risk, but with a complicated definition of burden.

    I am personally curious about this because at this time, it seems like the only criterion for opting for an ablation instead of continuing on drugs is whether your quality of life is lousy, either from poor control of the afib, or side effects of the drugs. However, I’ve heard that if afib goes on too much or too long, the probability of a successful ablation is lower. But how much is too much or too long before an ablation ceases being a good option? Do you have a guideline on this? Maybe a study using volunteers to keep records with their Watch or Kardia could quantify this. What do you think?

    Reply
  2. “Awking” immediately became part of both behavior and lexicon for me and my late wife. Chapeau, Ms.Skeptical! Now, I can’t be the only one who, on seeing an approaching pedestrian takes a big gulp of air and slowly releases it as the pedestrian passes. I have no idea what to call that (suggestions welcome) but I hope it doesn’t take me too long to break out of the habit.

    Reply

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