Cardiometabolic Risk Factor Control During Times of Crises and Beyond

The world is currently suffering through one the greatest crises of the last century. The coronavirus disease 2019 (COVID-19) pandemic is taking an enormous toll on public health and stretching medical resources in an unprecedented fashion. Our priorities are rightly focusing on meeting this existential threat. Nonetheless, we wish to call to attention that during major catastrophes the health consequences of chronic diseases, in particular cardiometabolic risk factors (CMRFs), continue unabated. In fact, new and serious problems arise part-and-parcel with the catastrophe and conspire to hamper our already imperfect ability to control CMRFs.^1,2 Our objective is to raise awareness that we need to anticipate (and not just be reactive to) the possible coming of a second crisis we term disastrous CMRFs. This refers to the worsening of CMRFs and their control rates during and following a major disaster.^1,2 Health care providers, in particular cardiologists, need to recognize the potential for this serious problem as it could promote a burgeoning of cardiovascular morbidity and mortality if not addressed. The COVID-19 pandemic should also serve as a wake-up call to the antiquated flaws in our healthcare model that collude to undermine the successful management of CMRFs in general.³ This current crisis can be a catalyst for optimizing practices and creating critical new capacities that will be beneficial moving forward and serve as a bulwark against future crises.

Chronic noncommunicable diseases, most notably CMRFs, account for the largest proportion of global mortality.³ Hypertension alone ranks as the single greatest risk factor for death.⁴ Unfortunately, <50% of hypertensive adults in the United States meet blood pressure goals with control rates even worse in many vulnerable communities.⁴ While it is not surprising that hypertension control is dismal (<15%–20%) among lower-income nations, the continued lack of success in the United States even during a long period of replete resources and prosperity is disconcerting. This should serve as an ominous forewarning for even further lapses in CMRF control when health care resources and patient-related factors (eg, finances, transportation) fundamental to the functioning of the most prevalent management paradigm (ie, free-for-serve, in-person visits) become constrained.⁵ The COVID-19 pandemic is just such a time.

What lessons can be learned from prior catastrophes? We have previously reviewed the studies demonstrating the adverse effects of natural disasters (earthquakes, hurricanes, tsunamis), societal upheavals (eg, humanitarian crises), and man-made environmental calamities (eg, nuclear accidents) on CMRF control.^1,2 Adverse effects on diabetes mellitus, hyperlipidemia, and obesity have been shown.² However, the most consistently reported finding is an elevation in blood pressure. Clinic, home, and ambulatory blood pressures can increase by 5 to 15 mm Hg for weeks to even months.^1,2 Key examples include studies of the 2009 earthquake in L’Aquila Italy⁶ and the triple-disaster (earthquake, tsunami, and nuclear accident) of 2011 in Fukushima Japan.⁷ In the United States, worsening control of hypertension and diabetes mellitus were observed following Hurricanes Katrina in 2005 and Sandy in 2012.^8,9 Of yet further concern is that these studies show that poor CMRF control can persist for prolonged periods even after the disaster has abated.

How do disasters elicit disastrous CMRFs? The Table lists the categories of factors and ensuing issues that conspire to worsen CMRF control.² Some issues arise immediately post-disaster and are likely short-lasting (eg, medication loss, sympathetic activation). Other issues (eg, noncompliance, poor diet and sleep, insurance difficulties) typically persist for longer periods. For example, medication compliance rates were chronically reduced following Hurricane Katrina and after the 1986 nuclear accident in Chernobyl Ukraine.^1,2,9 This temporally heterogeneous pattern of issues produces an increase in the risk for cardiovascular events over both the short- and long-term. In the hours to days following a major disaster there is a rapid increase in the rates of sudden cardiac death and acute myocardial infarction. Studies have also reported persistent elevations in the risk for cardiovascular morbidity and mortality (eg, heart failure) even weeks to months afterward.^2,9 We acknowledge there are limitations of many of the past studies. For example, a spike in event rates may be in part due to delayed case reporting post-disasters. Nevertheless, there is a consistency across a wide range of studies. We are also most concerned by the health ramifications of the long-lasting worsening of CMRF control in the affected population.

It is important to highlight that the current crisis of the COVID-19 pandemic is especially pernicious because it effects nearly every corner of the globe. Mobilizing outside resources for medical and humanitarian aid or relocating impacted populations is highly difficult. The major efforts thus far have needed to focus on curbing infection-related mortality. As with most prior disasters, the continued management of chronic CMRFs is thus currently taking a proverbial back seat and being made even more difficult due to restrictions on patient and clinical activities (eg, re-deployment of clinic staff, stay-at-home orders). This is compounding the preexisting short-comings of our health care model that already serve to undercut the capacity for controlling CMRFs.⁵

The primary take away lesson of this perspective is that disastrous CMRFs is a real phenomenon and that many responsible factors could be addressed to help lessen its impact (Table).^1,2 We aim to make a call to attention that our medical system needs to anticipate the potential for this second crisis during and even after the COVID-19 pandemic. Under emergency powers, the Centers for Medicare Services expanded telemedicine coverage in early 2020.¹⁰ We agree with the recent perspective by Keesara et al¹⁰ that this is a welcome and proactive move. A digital revolution in health care is past due. The management of chronic CMRFs is well-suited to be positively impacted due to the ability to assess blood pressure and diabetes mellitus control at home. The recent changes should be rapidly evaluated, modified as needed and made as universal as possible for all Americans from here on forward. The required infrastructure and electronic networks should be augmented to make this a near-term reality. This revolution would be particularly critical to help under-resourced populations where CMRFs are already an epidemic.⁴ If remote care capabilities were more widely available and patients and providers were already familiar with their usage, the impact of any future catastrophe could be mitigated.^1,2 This would take a substantial up-front and multi-faceted investment, but it is likely to pay-off not only during future crises but for the routine treatment of chronic CMRFs. Telemedicine and mobile health, particularly when patient feedback and treatments are semi-automated following algorithms, can improve hypertension control, reduce clinic visits, and may reduce overall costs.⁵ However, telemedicine is not a panacea. There are bound to be pitfalls, especially during disasters (eg, internet and power-outages) and holes in insurance coverage that need to be addressed. Particular problems can be foreseen for communities where inadequate health and technology literacy may require special attention. While a variety of benefits have been demonstrated in controlled studies,^5,10 the effectiveness of telemedicine on a wide-scale basis during routine healthcare has yet to be demonstrated. Along with unforeseen issues, the switch to remote care could occur inappropriately in some scenarios if not carefully considered (potentially worsening outcomes) or lead to more downstream testing and the need for additional in-person visits. As such, its adaptation into the healthcare setting will need to be continually validated and modified in an evidence-based manner. Finally, additional actions could potentially help improve the management of CMRFs during times of crises. We offer a list of strategies while acknowledging that the effectiveness of each approach requires validation (Table).

In closing, we propose a novel strategy that could play an integral role in helping to combat disastrous CMRFs. During disasters, many providers are required to devote the majority of effort to managing crisis-related illness(es). Even if telemedicine platforms were widely operating, the extra burdens would undermine their capacity to also successfully manage CMRFs in their other patients. We believe that a centralized system to help maintain seamless continuity of care in times of crises could be designed and made readily deployable whenever needed. Using telemedicine platforms specially trained providers (eg, nurses over-seen by a few physicians) could take over management of specific chronic conditions, such as CMRF control, among providers who wish to enroll. This dedicated CMRF-control program should follow predefined, yet adaptable, protocols and serve to replace (or assist) the ad hoc system of physician coverage by on-call colleagues or house officers. Communication among caregivers would be essential; however, the system would allow providers in the front lines to focus on the crisis without compromising care of other patients. There is also no reason this program could not be adapted to function during routine times. It could serve as an adjuvant to existing resources in helping to improve CMRF control, particularly among at-risk populations. For example, patients previously not participating in the healthcare system, those lacking access or living remote from care (eg, rural communities), or who simply wish to join could enroll. While pitfalls are certain to arise, such a program has the potential to be a valuable resource during times of crises and beyond. As we have briefly outlined, a collection of past failures has led to the genesis of disastrous CMRFs; however, with innovative thinking and modern technology, past need not be prologue.

Footnotes