Dr Deepak Bhatt Discusses Cardiologists' Role in COVID-19

During the surge of the pandemic in the northeast, we saw about a 40% reduction in cardiovascular admissions, while there was a higher rate of mortality among patients who came in, said Deepak L. Bhatt, MD, MPH, of Brigham and Women’s Hospital Heart & Vascular Center and Harvard Medical School.

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The American Journal of Managed Care® (AJMC®):Vascepa ( icosapent ethyl) has been shown to reduce risk of invasive surgery. This must be an attractive trait for patients now, during a pandemic. Are more physicians asking about prescribing the treatment as a result?

Dr. Bhatt: That's a great question. As far as REDUCE-IT REVASC, the analysis that you're referring to that was presented prior to this European Society of Cardiology, that is an analysis that was presented as a late breaking clinical trial at SCAI, the Society for Cardiovascular Angiography and Interventions with an encore presentation at the American Society of Preventive Cardiology. So, a lot of that data is already out there, though not yet published. So what REDUCE-IT REVASC did was look at the entire trial of REDUCE-IT, but then look at the endpoint of revascularization. And what was found was significant reductions in revascularization, with benefits that were significant by about 11 months, so an early benefit there, again much earlier than we previously appreciated.

Beyond that, when we looked at the types of revascularization, elective, urgent, emergent revascularization, each of those distinct categories of revascularization was significantly reduced. Then we even looked at the occurrence of PCI, percutaneous coronary intervention, during the trial, and also of CABG, coronary artery bypass grafting, during the trial, and each of those subtypes of revascularization were individually statistically significantly reduced, with effect sizes that were as large as what was seen decades ago in the 4S trial when statins first came on the scene. So it's a really large effect that we're seeing on revascularization, both in relative and also absolute terms. I find it remarkable that in a blinded trial with independent adjudication of endpoints that the endpoint of coronary artery bypass grafting is significantly reduced. That to me, reflects the substantial effect of icosapent ethyl on atherosclerosis and progression of atherosclerosis. And bolstering that concept, the 9-month data from the EVAPORATE trial, a mechanistic imaging study of icosapent ethyl, using the same drug and dose that REDUCE-IT did, there the 9-month data as published in cardiovascular research, the interim data already showed that multiple different markers of plaque composition and volume were favorably affected, significantly affected by icosapent ethyl versus placebo. Interestingly, the final results of that study were also presented as a late breaking clinical trial at ESC, the 18-month results. Now we have several sources of data showing us that icosapent ethyl does seem to kick in pretty early in particular, for endpoints of plaque progression and for endpoints of revascularization.

To answer the second part of your question, how is that relevant when we're living in a pandemic? That's a really great question. Of course, in the setting of a pandemic, in the Mass General Brigham Healthcare system, we've seen about a 40% reduction that occurred in cardiovascular admissions during the surge of the pandemic. I'm talking about late March, April, May, when things were really bad in the northeast, including in Boston. It isn't that patients suddenly weren't having heart attacks or didn't need care. They were understandably afraid to come into the hospital. There was a real downtick in cardiovascular admissions, but of those patients that came in, there was a higher rate of mortality. It's really a double whammy. Patients that should come in aren't coming in and the ones that come in are in pretty bad shape. I think in that context, anything we can do to further reduce cardiovascular risk, the sort of stuff we should really do anyway, but in particular, in the context of a pandemic, anything we can do to control risk factors and help keep patients appropriately out of the hospital, that is keep them well, and healthy and not really needing to go to the hospital would be even more important. I would say, for sure patients that are eligible for icosapent ethyl should be on it. But I would generalize that further to say if they should be on a statin you know, make sure they're on it, make sure they're taking it, make sure they are filling their prescriptions, and not just letting their prescription run out and not going to the pharmacy or, getting their prescriptions delivered, or however they get their medicines. I would extend that as well to things like blood pressure control, glycemic control in patients with diabetes. So it's very clear that patients that are dying from COVID-19 infection have heightened cardiovascular risk. I would at least like to think anything we do to reduce that cardiovascular risk, would alter their trajectory and perhaps decrease COVID-19-related morbidity and mortality. But even if that hypothesis isn't true, I would still be doing all these different things I mentioned, they're still the right thing to do. That is, if someone has indication to be on a statin or more intense glycemic or blood pressure control or on icosapent ethyl or whatever cardiovascular risk reduction is indicated in their case, well, they should be on it, even if it's not a pandemic, but perhaps it's even more important if they are in the middle of a pandemic. It's an interesting question.

AJMC®: In light of new data showing COVID-19 can cause structural changes in the hearts of otherwise healthy adults, how can cardiologists approach prescribing different treatments during the pandemic?

Dr. Bhatt: Well, there's no question that COVID-19 causes a lot of cardiovascular morbidity. Studies vary, but there's a significant chunk of patients with positive troponin, and I don't mean just low level, barely positive. I mean, within the range that one would normally say, oh, myocardial infarction, maybe not necessarily the slope of change, but the magnitude of proponent elevations can be quite high. There is substantial cardiovascular damage that's occurring in the context of COVID-19 related illnesses. It seems like persistent risk, including cardiovascular risk, including cardiopulmonary risk in people that survived COVID. Now, this is magnified in people with cardiovascular risk factors and people at older age and people with obesity and people with diabetes. Cardiovascular prevention, I think, is an important part or should be an important part of our overall strategy towards dealing with COVID-19. That is, controlling risk factors before people potentially get infected. Certainly those that have survived a COVID-19 illness to make sure to take care not only of any COVID-19 specific related issues that have developed into all sorts of issues, issues like cognitive dysfunction that have been raised and just lots of different problems. But in particular, to not forget that cardiovascular risk reduction is also part of what those patients often need because such a high prevalence of them have cardiovascular disease or risk factors for cardiovascular disease. I would say that even though it's easy to focus on the COVID-19 aspects of that patient's care and illness, to not forget all the important cardiovascular prevention things that we should normally be doing anyway, but in the setting of a patient that is at risk for or has COVID-19 we shouldn't forget about it. In fact, it might be even more important in that type of patient.