As if having cardiovascular disease or being at risk for developing it were not bad enough, the risk of severe illness from COVID-19 increases greatly if you have an underlying cardiovascular condition. Accordingly, now — more than ever — it is imperative that we take better care of our hearts.

Heart disease: The #1 killer

Cardiovascular disease (CVD) accounted for 859,125 deaths in the US in 2017 — claiming more lives than all forms of cancer and chronic lower respiratory disease combined.¹ Astoundingly, 121.5 million American adults had some form of cardiovascular disease between 2013 and 2016. Direct and indirect costs of total cardiovascular diseases and stroke were $351.3 billion in those same years.

Here’s a quick breakdown of the various cardiovascular diseases¹:

• Coronary artery disease (CAD) is the leading cause (42.6%) of deaths attributable to CVD. Learn more about CAD in the BeWell report, Healthy hearts: What to know and do about coronary artery disease.
• Stroke accounts for 17.0% of CVD.
• Hypertension, or high blood pressure (greater than 130/80 mm Hg), accounts for 10.5% of CVD. Learn more about hypertension in the BeWell report, New blood pressure guidelines: Why they matter.
• Other cardiovascular diseases make up the rest: heart failure (9.4%), diseases of the arteries (2.9%), and other cardiovascular diseases (17.6%).

Enter COVID-19: Adding fire to fire

People who have one or more of a long list of underlying uncontrolled medical conditions are at increased risk of contracting severe cases of COVID-19, possibly leading to death. These so-called “comorbidities” include diabetes; hypertension; lung, liver, and kidney disease; cancer patients on chemotherapy; smokers; transplant recipients; and patients taking steroids.²

Cardiovascular comorbidities — while not the only conditions that put one at risk of poorer outcomes from contracting COVID-19 — are a major category of concern. Early clinical data indicate that both the susceptibility to and the outcomes of COVID-19 are strongly associated with cardiovascular disease (CVD),³ and this category of comorbidities is associated with increased mortality.⁴

As reported during the Stanford Department of Medicine Grand Rounds (May 27) — and shown in the chart below, of all the COVID-19 hospitalizations at Stanford hospitals from the onset of the pandemic (Feb. 15, 2020) through May 17, hypertension was present in 32% of patients admitted. Other cardiac risk factors were as follows: 32% had hyperlipidemia, 13% atrial fibrillation, 13% coronary artery disease, and 9% had CHF (congestive heart failure) and cardiomyopathy.⁵

Focusing on hypertension

Not only are you far more likely to be hospitalized and become severely ill with COVID-19 if you have hypertension, you also have a two-fold greater risk of dying from the virus.^6,7

Since 108 million Americans — or nearly half of us — have hypertension,⁸ we think a few facts about this condition (also known as high blood pressure) bear repeating. As the CDC has stated:

• Because hypertension can lead to significant health problems — including heart attack, stroke, heart failure and kidney failure, more than 472,000 people died of it in 2017.⁹ That’s nearly 1,300 deaths each day.
• Only about 1 in 4 adults (24%) with hypertension have their condition under control.
• Half of adults (30 million) with blood pressure greater than or equal to 140/90 mm Hg who should be taking medication to control their blood pressure aren’t prescribed or aren’t taking medication.

Before you get COVID-19:
Prevent and treat hypertension

With a renewed focus on heart health due to COVID-19, why not use this news and this unusual time we are in to focus on the ways you can work to prevent  hypertension (and cardiovascular disease, generally), if you don’t have it yet; or to treat  hypertension — optimally — if you do have it?

In short, if you’re heart isn’t healthy, you could have a significantly harder time surviving COVID-19.

But here’s what you can do …

… if you’re generally healthy now:

Minimize your exposure to COVID-19. Maybe you think you’ve heard this low-tech solution so often that you yawn, but socially distancing is still the most effective way to avoid transmitting and contracting COVID-19 — as a new study has determined.¹⁰  Wearing masks and eye protection has also demonstrated proven efficacy in limiting spread.¹¹ Other measures, such as washing your hands often and cleaning/disinfecting surfaces, should also become daily habits: see updated CDC guidelines¹² and our reports, Home caregivers: Meeting the COVID-19 challenges and Guide to self-care: Coping with coronavirus.

Continue getting your routine checkups. Sheltering in place is no excuse for skipping health care: telephonic medicine is here to stay. Hypertension can develop at any age; and many people don’t even know they have it, because high blood pressure has no symptoms or warning signs.

Adopt a healthy lifestyle:

• Cease smoking and reduce excessive alcohol consumption, which can positively impact blood pressure levels (and also reduce the occurrence of another heart condition: atrial fibrillation, or “afib”¹³).
• Exercise regularly: Don’t let lockdown measures result in reduced physical activity! Medical providers are virtually all in agreement that walking each day is an important first step in managing blood pressure. Need further inspiration? See Wellness in the great outdoors and Moving as medicine.
• Maintain a healthy weight, and follow these dietary guidelines¹⁴:
  • Keep your intake of saturated fats low.
  • Consume less than 1,500 mg of sodium daily. What does this entail?:
    • Avoid using adding additional salt to foods. Instead, try seasoning alternatives.
    • Avoid processed or pre-packaged foods as these can have huge amounts of sodium.
    • Avoid canned foods, such as soups, fish, and vegetables.
    • Reduce the use of salt-laden condiments such as soy sauce, ketchup, mayonnaise, mustard, pickles, olives, and salty seasonings.
    • Read food labels; try to avoid any foods with over 400 mg of salt per serving as these can add up quickly to exceed the daily recommended sodium amount of 1,500 mg.
  • Emphasize fruits and vegetables, whole grains, and healthy fats and oils. Research shows that diets rich in these foods are associated with lower levels of markers for subclinical cardiac damage and strain in adults without pre-existing CVD.¹⁵
• Manage stress: Stress can lead to bad habits, such as poor diet, that can increase the risk of developing high blood pressure.¹⁶ A number of well-designed studies show that meditation can modestly lower blood pressure.¹⁷
• Stick to a regular sleep schedule. See Sleeping better for tips.

… if you have hypertension:

Be particularly vigiliant about the above recommendations.

If you are prescribed meds for hypertension, follow your prescription regimen. There is no firm evidence that hypertension or blood pressure drugs will increase a person’s risk of contracting COVID-19. Furthermore, should you contract COVID-19, patients taking common types of blood pressure medicines — angiotensin converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs) — should continue treatment unless otherwise advised by their physician, according to the American Heart Association, the Heart Failure Society of America and the American College of Cardiology.¹⁸  In a recent study directed by Stanford infectious-disease specialist Catherine Blish, MD, PhD, it was shown that COVID-19 patients taking these two very commonly used types of drugs for high blood pressure are at no heightened risk, as has been feared, for complications of COVID-19.¹⁹

Make sure that you have at least a 30-day supply of your heart disease medicines, including high cholesterol and high blood pressure medicines.

Avoid high blood pressure hazards. Various factors can be contributors to high blood pressure, so use extra caution with:

• Over-the-counter medications. Decongestants and painkillers called NSAIDs, such as naproxen and ibuprofen, can increase blood pressure. People with heart concerns should limit or avoid them.
• Some prescription drugs. People taking corticosteroids, oral birth control, immunosuppressants, mental health drugs and some cancer medications should monitor their blood pressure.
• Alcohol and caffeine. Limit these. No more than three cups of caffeinated beverages a day, for instance.
• Herbs and food combinations. Some herbal supplements such as licorice can raise blood pressure, and foods such as cured meats can interact with some antidepressants.

It is important to remain current with vaccinations, including the pneumococcal vaccine, given the increased risk of secondary bacterial infection with COVID-19; CVD patients should be vaccinated against influenza in accordance with current ACC/AHA guidelines.²⁰

Recognize a blood pressure emergency. A hypertensive crisis occurs when blood pressure rises quickly to readings of 180/120 or greater. If other symptoms occur — such as chest or back pain, numbness or weakness, loss of vision, or difficulty breathing or speaking — call 911.

Don’t hesitate to reach out. The American Heart Association’s free online Support Network connects people with similar health concerns. (Find “High Blood Pressure” under “Chronic Conditions.”) Get the latest information and recommendations on COVID-19 from the American Heart Association.

By Lane McKenna
August 2020

Related BeWell articles:
New blood pressure guidelines: Why they matter
Healthy hearts: What to know and do about coronary artery disease
Pregnancy and hypertension

Learn more:
Demystifying heart failure (a Stanford SCOPE  blog series)

Sources:

1. American Heart Association. 2020 Heart Disease and Stroke Statistical Update Fact Sheet At-a-Glance.
2. Centers for Disease Control and Prevention (CDC). Coronavirus (COVID-19): symptoms of coronavirus. 2020.
3. Nishiga, M et. al. COVID-19 and cardiovascular disease: from basic mechanisms to clinical perspectives. Nature Reviews Cardiology. Vol. 17, 543-558. July 20, 2020.
4. Sanyaolu A et. al. Cardiovascular comorbidity and its impact on patients with COVID-19. SN Compr Clin Med. June 25, 2020.
5. Studemeister, A. and Villarino, E. Stanford Department of Medicine Grand Rounds: May 27, 2020.
6. Gao, C et. al. Association of hypertension and antihypertensive treatment with COVID-19 mortality: a retrospective observational study. European Heart Journal. Volume 41, Issue 22, 2058–2066. June 7, 2020.
7. Lippi, G et. al. Hypertension in patients with coronavirus disease 2019 (COVID-19): a pooled analysis. Pol Arch Intern Med. 130(4):304-309. April 30, 2020.
8. Centers for Disease Control and Prevention (CDC). Hypertension Cascade: Hypertension Prevalence, Treatment and Control Estimates Among US Adults Aged 18 Years and Older Applying the Criteria From the American College of Cardiology and American Heart Association’s 2017 Hypertension Guideline—NHANES 2013–2016. Atlanta, GA: US Department of Health and Human Services; 2019.
9. Kirkland EB, Heincelman M, Bishu KG, et. al. Trends in healthcare expenditures among US adults with hypertension: national estimates, 2003-2014. J Am Heart Assoc. 2018;7:e008731.
10. Rubin, D et. al. Association of Social Distancing, Population Density, and Temperature With the Instantaneous Reproduction Number of SARS-CoV-2 in Counties Across the United States. JAMA Network Open. July 23, 2020.
11. Chu, D et. al. Physical distancing, face masks, and eye protection to prevent person-to-person transmission of SARS-CoV-2 and COVID-19: a systematic review and meta-analysis. Vol.395, Issue 10242; 1973-1987. June 27, 2020.
12. Centers for Disease Control and Prevention (CDC). How to protect yourself and others.
13. Voskoboinik, A. Alcohol Abstinence in Drinkers with Atrial Fibrillation. The New England Journal of Medicine. 2020; 382:20-28
14. Kim, MJ. Demystifying heart failure: Hold the salt and other healthy eating habits. Stanford Medicine SCOPE. August 2019.
15. Juraschek, SP et. al. Associations between dietary patterns and subclinical cardiac injury. Annals of Internal Medicine. June 16, 2020.
16. American Heart Association. Managing stress to control high blood pressure.
17. Levine GN et. al. Meditation and Cardiovascular Risk Reduction. A Scientific Statement From the American Heart Association. Journal of the American Heart Association. 2017.
18. American Heart Association. Patients taking ACE-i and ARBs who contract COVID-19 should continue treatment, unless otherwise advised by their physician. March 17, 2020.
19. Rubin, SJS et. al. Safety of ACE-I and ARB medications in COVID-19: A retrospective cohort study of inpatients and outpatients in California. Journal of Clinical and Translational Science. Cambridge University Press: 01 June 2020.
20. American College of Cardiology. ACC Clinical Bulletin: COVID-19 Clinical Guidance For the CV Care Team. March 6, 2020.