Santa Barbara Doctors ExtraCare – September 2020 Newsletter
September 2020 ExtraCare Newsletter
It’s hard to believe that fall is nearly upon us. While most of us have had to put some aspects of our lives on hold due to the pandemic, it’s amazing how fast the time continues to fly by. Yay to the citizens of Santa Barbara County for adhering to public health guidelines for masking and limiting social gatherings. Our daily numbers are declining and if we continue along this trajectory we may soon move into the “red zone”. This month we have chosen to discuss two relevant COVID-19 topics relating to heart health and vitamin D supplementation.
And let’s not forget that flu season will soon be upon us. We have received our initial shipments of high dose flu vaccine and have ample supply of our standard dose vaccines. It’s now time to get vaccinated. Please call the office to schedule an appointment for your flu shot.
Emerging Implications of Covid-19: Heart Health
Covid-19 has been increasingly proven to be a multi-organ assailant. As a spinoff to our article last month defining the most significant lung implications, new research has emerged that well defines the myriad of cardiovascular effects of Covid-19 infection.
This was discussed in 2 recent JAMA Cardiology articles, Linder et al and subsequently by Puntmann et al both of whom evaluated a broad spectrum of cardiac indices in Covid-19 patients.
In the first study, 39 autopsy cases were analyzed from patient’s who passed primarily from Covid-19 pneumonia. In 61.5% viral RNA was also identified in cardiac tissue, and of those, 2/3 were found at markedly high quantities. Advanced molecular techniques further localized viral RNA largely to the interstitial space, the areas between heart cells, and within inflammatory cells such as macrophages which had infiltrated the heart. Gene analysis confirmed high levels of protein production in at least 6 key genes involved in this pro-inflammatory response; this is remarkably similar to damage previously noted in lung tissue.
Puntmann et al took this study one step further and sought to distinguish acute vs chronic changes for better prognostication. 100 patients with confirmed Covid-19 were evaluated with cardiac MRI imaging an average of 71 days following diagnosis to evaluate multiple cardiac indices; 2/3 of these patients had symptoms classified as mild and did not require hospitalization. Compared to well matched control subjects, fully recovered Covid patients had statistically significant reduction in heart function; namely ejection fracture and filling pressures. Moreover, 1/3 of patients demonstrated MRI contrast enhancement of the heart and surrounding tissue which adds support to a pro-inflammatory response.
As we learn more about what Covid-19 does to normal tissue in the body, it’s extremely important to tease apart acute vs chronic changes. Why? Simply stated, acute changes are often expected, and considered reversible; chronic changes are coming as a greater surprise and might not be so easily fixed with the natural healing process. Its far too early to tell how the body will respond to these cellular processes, but what we do know from pro-inflammatory conditions within analogous organs, such as the liver, is that fibrosis has very limited reversibility.
These data support the need for larger studies with better inclusion criteria, improved statistics, and prospective evaluation for expanded heart failure metrics, but in the short term it reinforces the fact that avoidance of Covid-19 is best course of treatment with strict hand hygiene and social distancing. Treating Covid-19 like chicken pox, and allowing for simple herd immunity, doesn’t solve the primary problems addressed above. Similarly, only time will tell if a vaccine will effectively mitigate the pro-inflammatory changes that we highlight here. Although these articles raise more questions than answers, they highlight significant gaps in understanding that must be resolved before we let our guard down.
Outcomes of Cardiovascular Magnetic Resonance Imaging in Patients Recently Recovered From Covi-19: Puntmann et al. JAMA Cardiology, 27 July 2020
Association of Cardiac Infection with SARS-CoV-2 in Confirmed Covid-19 Autopsy Cases: Lindner et al. JAM Cardiology, 27 July 2020
Vitamin D deficiency and COVID-19
Since early in the pandemic, researchers have been looking at the link between vitamin D and COVID-19 infection. Previous studies have shown that vitamin D modulates immune function through effects on dendritic cells and T cells which may promote viral clearance and reduce inflammatory responses that produce symptoms. Also, higher levels of vitamin D have been shown to correlate with lower interleukin 6 levels, which are a major target for controlling cytokine storm in COVID-19. A recent PubMed search revealed over 50 citations linked to the topic. I wanted to highlight data from two recent publications.
The first study was recently published in JAMA online:
https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2770157
This study looked at over 4,000 patients in the University of Chicago system who sought testing for COVID-19. They identified 489 of these patients who had vitamin D levels performed within a year prior to their illness. They then investigated these individuals to see whether or not the vitamin D deficiency was adequately treated prior to their COVID testing and identified them as likely deficient or likely sufficient. They found that patients with likely deficient vitamin D status at the time of COVID-19 testing had an increased relative risk of testing positive for COVID-19 compared with patients with likely sufficient status at the time of COVID-19 testing, for an estimated mean rate in the deficient group of 21.6% vs 12.2% in the sufficient group.
The second citation highlights data presented at the recent American Society for Bone and Mineral Research Meeting:
These Italian researchers analyzed data from 103 adults (mean age, 66 years) admitted to San Luca Hospital in Milan, Italy, with COVID-19 symptoms; and 52 residents and employees of an Italian nursing home with mild symptoms who did not have respiratory dysfunction. Those with COVID-19 had vitamin D levels compared with 206 age- and sex-matched adults who had levels measured as part of a routine health visit from January to March.
The hospitalized COVID-19 group had lower vitamin D levels than the group with mild symptoms or the control group. Of the hospitalized group, 54 patients were admitted to the ICU with severe acute respiratory distress syndrome. When compared with patients who were hospitalized without ICU admission, those admitted to the ICU had lower vitamin D levels and higher interleukin-6 levels and having a low vitamin D level was associated with higher odds of ICU admission. Those who died of COVID-19 also had lower vitamin D levels and this association was independent of their IL-6 levels.
So as you can see, the data is not earth shattering but it does support the notion that vitamin D supplementation may be something that we can do now to possibly help prevent disease or improve our chances of survival during this COVID-19 pandemic.
At Santa Barbara Doctors, we measure vitamin D levels routinely on our patients as part of their annual physical laboratory workup and identify patients with levels <30 as insufficient. In general, most adults who don’t spend a lot of time in the sun, should supplement 1,000-2,000 IU per day of vitamin D. If your level is low we may recommend a more aggressive supplement approach. Because vitamin D is a fat soluble vitamin it is possible to take too much so make sure that you adhere to the recommended amounts.
Copyright © 2021 Barbara A. Hrach M.D. FACP, All rights reserved.
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