Libin Institute tackles COVID-19

Libin Cardiovascular Institute clinicians and researchers joined the fight against COVID-19, an important effort given that the virus can have a big impact on the heart.  

"What the basic science research has been telling us is that in the severe form of a COVID-19 infection, the endothelium – the inner lining of the blood vessels in our body – become adversely affected," said Dr. Imtiaz Ali, MD, Chief of Cardiac Surgery for Alberta Health Services (AHS).

The result is a higher risk of clotting, says Ali, explaining COVID-19 patients can develop clots in large blood vessels, including the aorta. In severe cases, the virus significantly increases the risk of stroke, heart attack and acute coronary syndrome.

"You have young patients presenting with strokes; young patients with no history of coronary artery disease or heart disease presenting with acute coronary syndrome and heart attacks; young patients presenting with renal failure – as a result, their kidney vessels are being damaged,” said Ali, noting the severe form of the virus only occurs in a minority of cases.

Ali said the virus can also cause a hyperinflammatory response in these blood vessels. Data indicates this response is related to pre-existing risks like high blood pressure, high cholesterol, history of coronary disease, kidney disease or stroke.

"But other factors, such the blood type that we have, have been implicated in whether or not patients get the severe form of the disease," Ali said, adding genetic factors are likely. 
Cardiologist and researcher Dr. Carlos Morillo, MD, who is the Section Chief of Cardiology for AHS, said many heart patients, fearing the virus, also delayed seeking treatment during the pandemic, which may have had a detrimental impact.   

"When you show up later to the hospital with a heart attack, the usual things that we can do – go in, open the artery and restore flow – these things are delayed, so other complications can arise," he said, adding it is important for people to seek treatment if they suspect heart issues.  
"We know the rate of people that are infected in the hospital – health-care workers, physicians – we get tested all the time and the rates of infection are very low, lower than in the community,” he said. “The safest place to be is the hospital."

Hospital avoidance during the pandemic

The Libin Institute’s Dr. Andrew McRae, MD, PhD, an emergency physician and researcher, along with medical student Dan Lane, PhD, studied hospital avoidance, including changes in use of emergency departments and EMS, during the first wave of the pandemic. 

They found that although emergency room visits dropped by about 30 per cent, EMS calls increased, more patients required admission to hospital and fewer patients followed EMS advice to go to the hospital. 

"What we also saw is that the rate of death outside of hospitals tripled during that period," McRae said, noting patients should seek help if they need it. "We would much rather see somebody and reassure them that we haven't found anything serious than take the chance on somebody staying home and potentially having a worse outcome because they waited too long to come to hospital.”

McRae is also involved in the Canadian COVID-19 Emergency Department Rapid Response Network – a group of 51 emergency departments systematically collecting data on patients tested for COVID-19. This research is intended to help emergency department health care providers accurately identify the patients likely to test positive for the virus and those likely to end up in the intensive care unit (ICU) or on a ventilator. 

This study will help inform critical operational decisions such as which patients should be sent to the ICU early and which should be kept in isolation to reduce transmission risk while optimizing limited isolation spaces and personal protective equipment. 

The data, McRae said, can also be paired with that from other studies looking at diagnostic tests and treatments for COVID-19 to provide a richer and more personalized look at how to best treat and test patients. 

Mental wellness needs for immigrant workers 

While others are looking at physical outcomes of COVID-19, Dr. Turin Tanvir Chowdhury, MBBS PhD, is focusing on finding culturally-sensitive and innovative ways of supporting the mental-health needs of immigrants who are working during the pandemic.

He said newcomers working at facilities like Walmart, Cargill or other essential services that remain open during lockdowns face a "chaotic scenario," that takes a toll on them. It’s a unique area of research. 

"Normally mental wellness is not a very recognized thing in newcomer communities. There's a huge stigma and a non-acceptance to talk about this issue," Chowdhury said.

Chowdhury's approach would have been limited had his team not spent the last five years working to build relationships within these communities.

"This relationship-building made it easier to convince them, 'Why don't we look at the wellness issues?'" he said, noting this includes both physical and mental health. 

Phase one of the project involves summarizing studies on what happened during previous epidemics such as Ebola, H1N1, SARS and MERS. In phase two, the team will engage with these communities to learn newcomers’ thoughts about mental wellbeing during the pandemic and if or how they have accessed available mental-wellness services.

"We will be going into the community and talking, engaging, and then measuring the mental-health issues or resilience issues," Chowdhury said. "That's the direct measurement part that will give us this idea about what can we do to improve things.”

Impact of positioning on critically ill patients

Respiratory specialist and researcher Dr. Jason Weatherald, MD, and his co-principal investigator Dr. Ken Parhar, section chief of Cardiac Critical Care, are investigating the impact of prone positioning (lying down facing downwards) in COVID-19 patients through the CORONA and COVI-PRONE studies, which are occurring in partnership with McMaster University.

The intervention places COVID patients suffering from acute respiratory distress syndrome (ARDS) on their stomach for 12 to 16 hours a day to improve oxygen consumption from the lungs. 

This position also takes the weight of the heart off the left lung, improves oxygen transfer to the blood and helps secretion and mucus drainage in the lungs. Prone positioning is currently used in intensive care units on critically ill, intubated patients who are sedated in order to tolerate the extended period on their stomach. Clinical trials have found it benefits this specific group, but the question remains if non-intubated patients will experience similar results. 

The CORONA and COVI-PRONE studies are looking to answer this, whether the positioning has benefits other than increasing oxygen levels, if it makes a difference in patient outcomes and the amount of time required in prone for it to be beneficial. The overall study includes two trials. COVI-PRONE is investigating if prone positioning can prevent intubation and CORONA is investigating if the positioning helps patients who don’t want to be intubated survive. 

"They're looking at two very different groups of people who are at risk of different outcomes," Weatherald said.