4 Ways to Mitigate Heart Disease Risk During COVID-19
Shilpa P. Saxena, MD
Heart disease is still the most significant mortality threat to Americans today. But now, cardiometabolic experts are asking this epigenetic question: How will the dramatic COVID-19-related changes to our daily lifestyles affect our patients’ risks for cardiovascular disease?
The latest CDC Heart Disease Facts published on April 8, 2020 were last reviewed December 2, 2019—well before the major effects of the COVID-19 pandemic had transformed the way much of our world operates. Here were the humbling numbers then:
One person dies every 37 seconds in the United States from CVD.
Approximately 647,000 Americans die from heart disease annually (1 in 4 deaths).
Two of every 10 CAD deaths occur in adults less than 65 years old.>
One person has a heart attack every 40 seconds.
That’s 850,000 Americans with heart attacks this past year.
For 605,000 people, it’s their first time.
One in every 5 of these heart attacks is silent—the damage is done, and the person is unaware of it.
For comparison, the CDC reported the following numbers for COVID-19 cases between January 21, 2020 and April 7, 2020:
Total US cases: 374,329
Total US deaths: 12,064
In our world of lifestyle, functional and integrative medicine, we agree epigenetic signals are created 24 hours a day, seven days a week, 365 days a year. What we eat, where we live, who we interact with, when we sleep, how we exercise, and most relevant today, how we stress can all cause biochemical modifications that affect our gene expression. Subsequently, our unique signals will turn certain inherited genes on or off over time. In the exam room, what we see clinically is the ultimate winner of the tug-o-war between “healthy” and “unhealthy” signals.
So, I ask myself: What are the epigenetic pulleys I can provide my patient so he/she can powerfully pull for a healthy state of function? And what are the epigenetic forces my patient is pulling against that we can reduce or eliminate so that undesired symptoms or disease states are mitigated?
Here are some compelling factors to consider as we all create an epigenetic-focused care plan with our patients during an evolving pandemic:
1. Cortisol acutely reduces inflammation; however, chronic secretion may result in resistance to its anti‐inflammatory properties, rendering the body vulnerable to inflammatory disorders, such as atherosclerosis (For example, high job demand has been associated with more rapid progression of carotid atherosclerosis).
THOUGHT: Social distancing and isolation has created major changes in our work environments and routines. The stress of this (combined with children at home for many) likely favors increases in cortisol, inflammation and resultant oxidative stress from this epigenetic player.
2. Increased inflammatory markers, such as C‐reactive protein and interleukin‐6, have prospectively predicted coronary events in healthy asymptomatic populations, and elevated levels of C‐reactive protein and other proinflammatory cytokines have been noted in individuals with depression.
THOUGHT: Mitigating the effects of inflammation may prove useful to reduce CVD risks and events as many Americans work through the physical and psychological adaptation to change.
3. Endothelial dysfunction is characterized by reduced coronary blood flow secondary to impaired vasoreactivity of the coronary microcirculation and/or epicardial vessels. It can precede atherosclerosis and may independently lead to adverse CVD events. Short‐term episodes of mental stress have been shown to cause reversible endothelial dysfunction in healthy individuals. Given its central role to several potential mechanisms related to both work stress and CHD, including inflammation, and modifiable cardiovascular risk factors, endothelial dysfunction may play a pivotal role in the link between work stress and cardiovascular health and could potentially offer an integrated index of risk.
THOUGHT: Leveraging nutrient therapy to promote healthy endothelial function could play a role in reducing CVD morbidity and mortality in at-risk patients during this extended COVID-19 stress state for many.
4. Based on the inflammatory effects of the virus, there are theoretical risks that the viral infection could cause rupture of atherosclerotic plaques (fatty deposits) in the coronary arteries, leading to acute coronary syndromes (heart attack).
THOUGHT: As we manage patients with known or suspected COVID-19, it is imperative we simultaneously assess for an increased risk for cardiovascular morbidity and/or mortality. Assessing and tracking patients with advanced lipid and inflammation testing pre- and post-viral infection could be useful in more personalized management of at-risk patients (e.g. most adult Americans). Elevations in hsCRP, oxLDL and Lp-PLA2 could prompt measures to optimize appropriate cardioprotective epigenetic signals through diet, lifestyle and appropriate nutrient therapy when aggressive or urgent pharmaceutical therapy is not clinically indicated.
THOUGHT: Inside endothelial cells, certain flavonoids may increase the production of nitric oxide, a potent vasodilator that is reduced in a dysfunctional endothelium. Several randomized controlled trials have demonstrated that consumption of certain flavonoid-rich beverages improves endothelial function in patients with CHD, elevated blood cholesterol, or type 2 diabetes. Specific evidence-based nutraceuticals such as pomegranate extract, olive fruit extract, French maritime pine bark extract, ECGC and quercetin may worthy considerations.
These are uncertain times. Fortunately, we are no stranger to uncertainty, having chosen a career in the science and art of medicine. Using the guiding principles of epigenetics, systems biology, shared decision making and therapeutic partnership, we are poised to be the clinicians society needs now, and the leaders we will need tomorrow after humbly learning what there is to learn from COVID-19 and its effects on our planet.
Shilpa P. Saxena, MD, IFMCP
Shilpa P. Saxena, MD is a Board-Certified Family Practice physician whose passion and purpose come to life through sharing her innovative patient education and practice management solutions in her classic ‘keep it simple’ style. She serves as Faculty with the Institute for Functional Medicine, the Arizona Center for Integrative Medicine, Osher Center for Integrative Medicine at the University of Miami Miller School of Medicine, the Metabolic Medical Institute at George Washington University and most recently, joined the Lifestyle Matrix Resource Center serving as the Clinical Expert for the CM Vitals Program. Dr. Saxena is an expert in the Group Visit medical model, creator of Group Visit Toolkits, and co-author of The Ingredients Matter: India.