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-19 (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 general³. 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 non-communicable diseases, most notably CMRFs, account for the largest proportion of global mortality³. Hypertension alone ranks as the single greatest risk factor for death⁴. Unfortunately, <50% of hypertensive adults in the United States meet BP goals with control rates even worse in many vulnerable communities⁴. 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/or patient-related factors (e.g., finances, transportation) fundamental to the functioning of the most prevalent management paradigm (i.e., free-for-serve, in-person visits) become constrained⁵. 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 (e.g., humanitarian crises) and man-made environmental calamities (e.g., nuclear accidents) on CMRF control^1,2. Adverse effects on diabetes, hyperlipidemia and obesity have been shown². However, the most consistently-reported finding is an elevation in BP. Clinic, home and ambulatory BPs can increase by 5–15 mm Hg for weeks to even months^1,2. Key examples include studies of the 2009 earthquake in L’Aqulia Italy⁶ and the triple-disaster (earthquake, tsunami and nuclear accident) of 2011 in Fukushima Japan⁷. In the United States, worsening control of hypertension and diabetes 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 control². Some issues arise immediately post-disaster and are likely short-lasting (e.g., medication loss, sympathetic activation). Other issues (e.g., 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. 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 (e.g., 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 (e.g., 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 CMRFs⁵.

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 2020¹⁰. We agree with the recent perspective by Keesara et al. that this is a welcome and pro-active move¹⁰. 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 BP and diabetes 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 epidemic⁴. 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 feed-back and treatments are semi-automated following algorithms, can improve hypertension control, reduce clinic visits, and may reduce overall costs⁵. However, telemedicine is not a panacea. There are bound to be pitfalls, especially during disasters (e.g., 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).

Table.

Causes of and potential remedies for “disastrous cardio-metabolic risk factors”

Categories	Issues That Could Worsen CMRF Control	Potential Strategies That Could Help Mitigate The Issues
Social factors	Financial hardships
	Additional job responsibilities and insecurities
	Reduced capacity for lifestyle management	Expand insurance coverage for remote consults to include non-physician-based health promotion and education (e.g. dietary and exercise therapies)
	Insurance coverage difficulties	Alternative insurance paradigms and expanded coverage systems (e.g., “medicare for all”) that are part of a larger debate might be helpful.
	Restricted available time for clinic visits	Expand non-traditional healthcare settings (e.g., barber shops, salons) in communities to improve access and proximity to care5
	Transportation and travel difficulties	Improving access and reducing costs of medical transportation. Use of non-traditional care settings. Use of telehealth and a dedicated remote “CMRF-control program”
	Decreased medication and lifestyle compliance	Involve proven methods to enhance persistence (e.g., mobile health platforms, text/call reminders)5
	Medication loss	Free home medication delivery, secure medication vending-machines. Increase the pool of independent prescribers (e.g., pharmacists)
Biological responses	Endothelial dysfunction	Improve CMRF control
	Chronic post-traumatic stress disorder	Expand insurance coverage for remote consults to also include counselling for psychological disorders by physicians and other mental health professionals
	Reduced sleep duration/quality (circadian disruption)	Expand insurance coverage for remote consults to also include counselling and medication therapy for sleep disorders when appropriate
	SNS and HPAA activation	Use of anti-SNS medications (e.g., beta blockers or clonidine) when appropriate.
	Poor diet - alcohol abuse, increased dietary sodium	Expand insurance coverage for remote consults to also include dieticians
	Weight gain, inactivity	Expand insurance coverage for remote consults to also include dieticians and exercise therapists
Healthcare system failures	Reduced medication availability	Adequate stock-pile of “essential” cardiovascular medications (e.g., statins, BP medications)
	Reduced clinic space and time availability	Telemedicine and non-traditional settings of care Use a dedicated remote “CMRF-control program”
	Fewer health care providers and reduced availability	Telemedicine and non-traditional settings of care Use a dedicated remote “CMRF-control program”
	Decrease in medical resources and equipment	Telemedicine and non-traditional settings of care Use a dedicated remote “CMRF-control program”
	Prioritization of care to urgent health issues	Education of the importance of “disastrous CMRFs” to healthcare providers and patients. Use a dedicated remote “CMRF-control program”
	Down-playing continued importance of CMRF control by providers	Education of the importance of “disastrous CMRFs” to healthcare providers and patients. Use a dedicated remote “CMRF-control program”

BP, blood pressure; CMRF, cardio-metabolic risk factors; HPAA, hypothalamic-pituitary-adrenal axis; SNS, sympathetic nervous system

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 (e.g., 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 pre-defined, 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 couldn’t 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 (e.g., 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.