453 - Long COVID, CVD Chemoprophylaxis, The Rest of Your Story

From the CDC and the Literature

1)  “Long Covid” – Caring for Persons with Post-COVID Conditions

In August of 2021, we provided an overview of “Long-COVID” and caring for persons with post-COVID conditions in a Take 3 Pointer (Take 3 August 13, 2021).  Although it appears most patients infected with SARS-CoV-2  recover within a few weeks, some experience ongoing post–COVID-19 symptoms more than 4 weeks post infection, with more common longer-term symptoms including tiredness or fatigue, cognition and/or concentration concerns, headache, loss of taste or smell, palpitations, shortness of breath and/or dyspnea on exertion, chest pain, chronic cough, joint or muscle pains, insomnia, depression and/or anxiety, and low-grade fever.  Since last August, more information continues to be published about this condition. 

In May, the Morbidity and Mortality Weekly Report provided an update of data related to post-COVID conditions through November of 2021.   In this study, a retrospective matched cohort design was used to analyze EHR data from March 2020–November 2021 using Cerner Real-World Data, a national, deidentified data set of approximately 63.4 million unique adult records from 110 data contributors in 50 states.

The data identified over 350,000 persons diagnosed with COVID-19 and these were matched against 1.6 million case controls.  When comparing the occurrence of 26 clinical conditions previously attributed to post-COVID illness, the authors found that approximately 20% of COVID-19 survivors aged 18–64 years and 25% of survivors aged ≥65 years experienced an incident condition that might be attributable to previous COVID-19 infection.

The data analysis indicated that independent of age group, the highest risk ratios were for acute pulmonary embolism and respiratory symptoms.  Those aged ≥65 years in this study were at increased risk for neurologic conditions, as well as for mood disorders, other mental conditions, anxiety, and substance-related disorders.  The authors note that neurocognitive symptoms have been reported to persist for up to 1 year after acute infection and might persist longer.   

Mark’s Comments: 

Although there is an ICD-10-CM code for “Post COVID-19 condition, unspecified” (U09.9) and the Department of Health and Human Services has provided guidance on the diagnosis of “long COVID” as a disability under the Americans with Disabilities Act (see second reference), it is important to recognize there is much that is still not understood about this spectrum of conditions.  The long-COVID RECOVER research initiative (3^rd reference) is designed to learn more. 

Remember that at this time no laboratory test can definitively distinguish post-COVID conditions from other etiologies, in part due to the heterogeneity of them.  Therefore, before ordering laboratory testing, the goals of testing should be clear to the healthcare professional and to the patient.  Any laboratory testing should be guided by the patient history, physical examination, and clinical findings.  Additionally, transparency is important for the process of goal setting; clinicians should advise patients that post-COVID conditions are not yet well understood and assure them that regular follow-up and support will continue to be provided as new information emerges. 

Although clinics are emerging to help focus on this condition, the potential number of people who are likely experiencing some post-COVID sequalae is staggering.  As such, it will be important for we who practice primary care medicine to be part of and often central to the treatment team for this. 

References:

·         Bull-Otterson, L et al. Post–COVID Conditions Among Adult COVID-19 Survivors Aged 18–64 and ≥65 Years — United States, March 2020–November 2021. CDC Morb Mortal Wkly Rep 27 May 2022. 71(21);713–717. Link

·         US Department of Health and Human Services.  Guidance on “Long COVID” as a Disability Under the ADA, Section 504, and Section 1557.  26 July 2021. Link

·         Long COVID RECOVER Research Initiative:  Link

From the US Preventive Services Task Force (USPSTF)

2)  Chemoprophylaxis of Cardiovascular Disease

Two US Preventive Services Task Force recommendations have recently been published that address our attempts to routinely give medications to prevent cardiovascular disease – i.e., aspirin and vitamins/minerals.

We addressed the draft aspirin recommendation, which has not changed significantly in the final version, in October 2021:

·         Adults ages 40 to 59 years with a 10% or greater 10-year CVD risk:

o   The decision to initiate low-dose aspirin use for the primary prevention of CVD in adults ages 40 to 59 years who have a 10% or greater 10-year CVD risk should be an individual one. Evidence indicates that the net benefit of aspirin use in this group is small. Persons who are not at increased risk for bleeding and are willing to take low-dose aspirin daily are more likely to benefit. C recommendation

·         Adults aged 60 years or older

o   The USPSTF recommends against initiating low-dose aspirin use for the primary prevention of CVD in adults aged 60 years or older. D recommendation

It’s important to remember that these recommendations are only about when to start aspirin therapy for primary prevention. Patients with cardiovascular disease (a secondary prevention situation) should continue aspirin in the absence of contraindications. Stopping aspirin for primary prevention is suggested at age 75 when the risk of bleeding is thought to outweigh the benefits of aspirin.

Vitamins and minerals have no apparent benefit in preventing cardiovascular disease (or cancer). Specifically, the USPSTF:

·         recommends against the use of beta carotene or vitamin E supplements for the prevention of cardiovascular disease or cancer. D recommendation

·         concludes that the current evidence is insufficient to assess the balance of benefits and harms of the use of multivitamin supplements for the prevention of cardiovascular disease or cancer. I statement

·         concludes that the current evidence is insufficient to assess the balance of benefits and harms of the use of single- or paired-nutrient supplements (other than beta carotene and vitamin E) for the prevention of cardiovascular disease or cancer. I statement

Good quality research found that beta-carotene and vitamin E has no benefit in reducing cardiovascular disease or cancer, and beta-carotene may result in a small increase in lung cancer risk. For multivitamins and vitamin combinations, there is no evidence supporting their benefit.

John’s Comments:

Primary prevention is an important topic in primary care. Because it is intended for large populations with a low average risk for disease, many interventions are not potent enough to make a measurable benefit. Discussing the overall risk of cardiovascular disease should already be routine in primary care, and aspirin can easily be integrated as an option for risk along with statins.

We should let go of routinely recommending vitamins/supplements until high-quality evidence comes along. An accompanying editorial reviews the possible reasons for our overuse of vitamins/supplements, including “action bias – a desire, all else equal, to err toward harms of commission rather than omission.” Examining the role of these biases in our decision making may be worthwhile.

References:

1.    US Preventive Services Task Force. Aspirin Use to Prevent Cardiovascular Disease: US Preventive Services Task Force Recommendation Statement. JAMA. 2022;327(16):1577-1584. Link

2.    US Preventive Services Task Force. Vitamin, Mineral, and Multivitamin Supplementation to Prevent Cardiovascular Disease and Cancer: US Preventive Services Task Force Recommendation Statement. JAMA. 2022;327(23):2326-2333. Link

From PeerRxMed ( www.PeerRxMed.org )

3)  What’s the Rest of Your Story

“And now you know … the rest of the story.”  Paul Harvey, legendary radio personality   

While growing up, I can remember my grandmother listening regularly to Paul Harvey’s radio show, “The Rest of the Story.”  At his peak of popularity, the legendary commentator delivered his daily news and feature broadcast to more than 25 million listeners, and each segment would include short stories that focused on forgotten or little-known facts about historical events and personalities.  These stories would always finish with a surprise twist and his trademark ending:  “And now you know . . . the rest of the story.”

Each of us has our own “news and feature broadcast” playing daily in our minds to an audience of 1.  What are the stories being told about yourself on your show?  I like to call them our “I am,” or, when we’re feeling particularly disconnected from ourselves, our “you are” stories.   Perhaps yours tell of feeling overwhelmed, weary, angry, frustrated, or “done with this!”  They might scold that “you are” … stupid, pathetic, ugly, lonely or an imposter.  Or maybe they affirm “I am” grateful, blessed, loved, beautiful, smart.  Those two simple words, “I am” or “you are,” have incredible power, as they imply a core identity … an essence.  And too often what’s “playing” on our broadcast is not particularly uplifting.     

But fortunately, the story you are telling is not the whole story.  There are other “you are” stories beyond the ones you tell yourself.  Those stories come from the perspective of those who know us well – those who see in us ways we often don’t see (or even want to see) ourselves. 

This past April I had the privilege of co-facilitating a day-long retreat for our first-year Family Medicine residents.  The entire day was a powerful time of connection, sharing, laughter, and yes, some tears.  To close our time together, we held a circle of affirmation.  This consisted of focusing on one person at a time with each of us taking turns saying their name and then sharing an attribute or characteristic about that person that we greatly admired or appreciated.  The recipient’s role was to make eye contact, listen intently, and when each person was finished, to say “thank you.”    

Needless to say, what was shared during our time together was an infusion of love and blessing and encouragement for everyone there.  We left the retreat “better” than when we arrived, with revised stories – stories that much more accurately reflected who each of us are in the eyes of our colleagues … stories that reflected a deeper truth.  And we were each reminded of the importance of regularly sharing such stories with those who matter to us – those who, like us, desperately need to hear … the rest of the story.

______________

Mark and John

Carilion Clinic Department of Family and Community Medicine

Feel free to forward Take 3 to your colleagues. Glad to add them to the distribution list.

Email: mhgreenawald@carilionclinic.org