The 11th Trial of a Cardiovascular Clinical Trialist: Coronavirus 2, Part 7: COVID-19, What Next?

This seventh editorial in Cardiology in Review related to Covid-19, marks the third year of the pandemic. It does appear that this healthcare crisis, at least in the United States, is coming to an end. The fourth infection surge, related to the Omicron variant of the coronavirus, is waning as both hospitalizations and fatalities are now fewer in number. Clearly, the vaccines have helped to dissipate both the frequency and severity of illness.[1]

Despite the clamor of the antivaccinators, I can attest to the overall success of the vaccination program in our region of New York State, the Hudson Valley, where over 1 million individuals (adults and children) received the injections with a minimal side effect rate.

I was a vaccinator and site leader through 2021 and early 2022, working in our hospital facility and at the County Center in Westchester. In this pursuit, we were supported by members of the administrative, physician, nursing, and pharmacy staffs, along with the State and County Police, the Department of Health, and the National Guard. The vaccination program was a great public health effort, and attests to what hard work and dedication toward the common good can accomplish. The development of the vaccine was also a wonderful example of what a government-private industry partnership should be.

There is still a need to vaccinate those susceptible individuals who continue to refuse the injections. I am a firm believer that there should have been a federal mandate to vaccinate, and the process should never have been politicized as it has been.

Mandates do work. As a young boy, I remember receiving various vaccines, including polio and small pox. One could not go to school without having received them. Subsequently, polio and small pox disappeared, as have other diseases of childhood.

Despite the successes with Covid-19 treatment and prevention, there are still challenges related to recovery from the different coronavirus variants. The post-Covid “long hauler syndrome” seen in recovered patients are real entities with both mental health and somatic complaints being described.[2] However, in most patients these symptoms are short lived in their duration.

New treatments for acute Covid-19 infections have become available that include new antiviral drugs, which can be administered by mouth. Poxlovid (Pfizer)[3] combines nirmatrelvir with the HIV-1 protease ritonavir. Nirmatrelvir inhibits the severe acute respiratory system coronavirus (SARS-CoV-2) main protease, preventing viral replication. Also available is molnupiravir, an antiviral that targets viral RNA polymerase.[4]

As in previous issues of Cardiology in Review, 3 new articles related to Covid-19 are included within.

First, Welty et al[5] review updated data regarding the cardiac complications associated with Covid-19 infection. These include myocarditis, heart failure, and coagulopathy. The role of elevated troponin levels as a diagnostic and prognostic test in Covid-19 is also highlighted.

Second, Sreenivasin et al[6] report on the clinical experiences with extracorporeal membrane oxygenation as a reserve therapy for patients with severe Covid-19 infection, complicated by acute respiratory distress syndrome that is refractory to mechanical ventilation. The clinical outcomes in patients receiving extracorporeal membrane oxygenation appear to be similar to non-Covid patients who also receive this therapy.

Third, Kim et al[7] report on the cardiometabolic abnormalities associated with an increased risk of Covid and its severity. These include hyperglycemia, insulin resistance, dyslipidemia, hypertension, abdominal distention. Additional environmental risk factors for disease severity include cigarette smoking, a sedentary life style, poor diet, and poverty. The exact mechanisms for increased clinical severity in patients with Covid-19 with cardiometabolic abnormalities have not been elucidated. The effectiveness of vaccinations in patients having cardiometabolic abnormalities is also discussed.

What a ride! What next?

During my lifetime and over 50 years of medical practice, there has been nothing that compares with the Covid-19 pandemic, and the political and economic ramifications that have come along with it. Starting with the first severe case presentation during the winter of 2020, our intensive care units were swollen beyond capacity, and now in 2022 after 1 million deaths, the acute illness appears to be under control except in high-risk, unvaccinated individuals. We may be coming to the end of masking and social distancing.

As of now, we no longer have Covid-19 wards in the hospital. Overall, despite all the challenges related to Covid-19, the United States has done relatively well in dealing with it, and is now positioned to face the upcoming health crises in the years to come.