We still know little about the relationship between coronavirus (COVID-19) and cardiovascular disease. That is why cardiologist Folkert Asselbergs has set up an international study. “We urgently need data to better understand the disease course of corona in patients with cardiovascular disease.” Hospitals can participate by including cardiac data from patients with corona in the CAPACITY registry.
There is considerable speculation on social media about COVID-19 and the risks to people with cardiovascular disease. “Patients get restless about that,” cardiologist Folkert Asselbergs knows. “We get a lot of questions from cardiovascular patients: whether they are more vulnerable, about risks and about their medication.”
What do we really know about this by now? Cardiovascular patients can become seriously ill from the coronavirus and are more likely to die from it. Among patients with COVID-19 who end up in the hospital, there seem to be more people with diabetes, high blood pressure (hypertension) and/or a history of cardiovascular disease. Conversely, healthy people may develop symptoms such as heart failure or inflammation of the heart muscle because of COVID-19.
How does it come about? For example, do patients with corona have high blood pressure due to their higher average age, or is there a relationship between cardiovascular disease and COVID-19? “It’s a chicken-or-egg issue,” Folkert says. “In order to treat COVID patients better, it is important that we get more clarity soon. I don’t want to make assumptions without solid scientific research. First the facts.”
It seems logical that a sum of lung problems from COVID-19 and cardiovascular disease increases the risk of complications. After all, lungs, heart and vessels work closely together in the body to deliver oxygen everywhere. But real insight into how corona and cardiovascular disease affect each other is not yet available. Folkert therefore took the initiative for the European CAPACITY study. The aim is to collect medical data from as many patients with corona as possible as quickly as possible:
1. about (possible) cardiovascular complaints in the past;
2. during the diagnosis of COVID-19;
3. about (subsequent) complications.
Quite a tour de force, because the research had to be able to start just about immediately: after all, the coronary crisis is going on now. “It is extraordinary that important parties such as the Dutch Society of Cardiology, the Heart Foundation, the Harteraad, the Dutch Heart Registration and the Working Group of Cardiological Centers Netherlands, united in the Dutch CardioVascular Alliance, managed to make this research possible together within two weeks,” Asselbergs emphasized. The Healthcare and Youth Inspectorate agreed to the method of data collection within days, and the Medical Ethical Review Committee (METC) Utrecht gave the green light within 24 hours. Folkert: “That we can do this research is thanks to the efforts of many.”
Especially for the study, the CAPACITY website was launched on March 27. On it, European hospitals can share medical data of all admitted patients with a positive test result or a high suspicion of COVID-19. Asselbergs warmly invites all hospitals to join the initiative through the CAPACITY COVID Registry as soon as possible.
Of the 71 Dutch hospitals, 44 are now participating in this observational study. In it – to be clear – no treatments are tested, only medical data are collected and analyzed. Hospitals from Belgium, Germany and the United Kingdom are also eager to participate and share data.
The study’s organizers are supporting hospitals with all the necessary documents to quickly get permission from their METC and board of directors or management. “In many cases this succeeds within 24 hours,” Folkert knows. If necessary, Dutch hospitals receive help from the Werkgroep Cardiologische centra Nederland, a research network of nearly 60 cardiovascular institutes. This network helps to start registration and data collection. Folkert: “Much scientific research is temporarily at a standstill due to the corona crisis. Researchers and research nurses who are forced to work from home now help remotely to process medical data in the registration.”
Hospitals already share medical data from patients with COVID-19 in the World Health Organization’s ISARIC registry. CAPACITY is expanding that research to include data on cardiovascular disease to find out whether COVID patients already had it, whether they belonged to a risk group, what their cardiac history looked like and what is known about it in their medical records. Examples include blood test results, cardiac ultrasounds and/or MRIs, electrocardiograms, treatments and surgeries, and cardiovascular test results at seven and 30 days after hospitalization because of COVID-19.
Thus, physicians and nurses do not need to perform additional measurements or operations on patients for the CAPACITY study. In fact, all medical data needed for the study are already in the patient record because they are either known from the past or are recorded by default with COVID-19. In the CAPACITY registry, these medical data are stored securely and encrypted. Scientific researchers then analyze them. Asselbergs: “Every hospital can thus help to gain more insight into the relationship between COVID-19 and cardiovascular diseases.”
Now that registration has started, Folkert expects the first results as early as mid-April. After all, by then much will already be known about the characteristics of patients with corona on admission to the hospital. For example, how many were already being treated for cardiovascular disease. And what complaints the patients had on admission: shortness of breath or chest pain, for example? “The first analysis will already provide insight into the differences in complaints and symptoms between COVID patients with and without cardiovascular disease. We will also then know more about differences between age groups and between men and women.”
In the following weeks, more knowledge will emerge about the course of the disease. Folkert: “The most pressing question is which cardiovascular patients can reasonably withstand hospitalization because of COVID-19 and which have an increased risk of ending up in the ICU or even dying. The question is also what we can or cannot do about that with treatments.”
In six weeks to two months, he expects more knowledge about the impact of cardiac medications on COVID-19 and that of anti-coronary agents (such as viral inhibitors and chloroquine) on cardiovascular disease. This includes looking at details such as dosing and how drugs may affect each other. “In the long term, this research also provides opportunities to be better prepared for new outbreaks in the future,” he says. “It’s not a pleasant idea, but COVID-19 will not be the last virus we have to deal with. So let’s learn as much as we can from what’s happening now.”
Normally, patients must be asked for consent to participate in a study. In this case, it’s the other way around. Hospitals may enter all medical records of patients with corona into the CAPACITY registry for the study. Patients who do not want this – or their legal representative – can object by filling out a simple form.
“There are several reasons why we work this way,” Folkert explains. “First of all, this research serves a great public interest, because the results can help to quickly improve the care of very sick patients. In addition, you cannot ask people who are being ventilated and put to sleep for consent. We also want to keep contacts to a minimum and not put an additional burden on the care staff. They obviously have other things on their minds when caring for patients with COVID-19.” And there is another reason for doing it this way. “Explaining about research, asking permission and signing papers quite often leads to you only getting patients in a study who understand all that. So as a result, you get a selection of the population. We don’t want that. The point is to quickly get a good picture of the relationship between corona and cardiovascular disease in people from the entire population.”
Cardiologist Folkert Asselbergs recently participated in a Facebook event of the Heart Foundation titled “Heart and/or vascular patient and questions about corona virus?” Together with family physician Monique Tjon-A-Tsien, he answered questions about COVID-19, risks and medication. On the websites of the Harteraad and those of the Heart Foundation are coronadossiers with answers to frequently asked questions.
