A perpetual state of bad dreams: The prevention and management of cardiovascular disease in the COVID-19 pandemic era and beyond

The sense of relief when waking up from a bad dream can be rather powerful, knowing that what you were experiencing in the dream is not reality. The world is emerging from the bad dream known as the coronavirus disease 2019 (COVID-19) pandemic, unfortunately, this bad dream was and continues to be all too real. While we will be living with COVID-19 and its aftereffects for the foreseeable future (e.g., emergence of variants with spikes in infection rates), we have passed the initial global health crisis, characterized by broad viral spread, hospitalization rates that pushed healthcare systems to their limits around the world, and high mortality rates, particularly in those: 1) with unhealthy lifestyle characteristics; 2) with co-existing chronic medical conditions; and 3) who live in underserved communities.1, 2, 3, 4, 5 Often, these risk factors for a poor outcome with COVID-19 infection clustered together, creating a new Syndemic.^{2 , 6 , 7} While it is normal and justified for the world to feel a sense of relief as we wake up from the COVID-19 bad dream, we cannot relax for long. The reason being we have been existing in an unhealthy living-chronic disease bad dream for decades, a bad dream that will not go away and makes numerous situations, including the COVID-19 pandemic, far worse. Cardiovascular disease (CVD) is an integral component of the chronic disease health crisis we have lived with for decades, also identified as a pandemic in its own right.⁸ Like COVID-19, the CVD bad dream is all too real.

CVD was a leading cause of morbidity and mortality around the world prior to the COVID-19 pandemic and will continue to be as we move forward.^{8 , 9} It appears the COVID-19 pandemic has negatively impacted the progress we have made in combatting CVD. Recent data indicates CVD mortality, which has been declining for decades, reversed course due to COVID-19, with a sharp rise in CVD mortality in 2020.¹⁰ Moreover, it appears that CVD prevalence and mortality could yet be further compounded by the long-term consequences of COVID-19 in the years ahead.¹¹ Unquestionably, the health crisis with CVD and associated unhealthy lifestyle risk factors remains prominent in the COVID-19 pandemic era, although the attention and focus historically afforded CVD prevention and management has transiently decreased for obvious reasons; the world had to focus on the most pressing bad dream. Moreover, there are clear inter-relationships between CVD, its associated risk factors (e.g., unhealthy lifestyle behaviors), and COVID-19 infection.^{7 , 12} The impact of the COVID-19 pandemic on how we prevent and manage CVD will also be felt for years to come – initial signs indicate the impact may be catastrophic.

This edition of PCVD will focus on the impact of COVID-19 on the prevention and management of CVD. Highlights from the reviews and original research included in this edition of PCVD are as follows: 1) It has rapidly become clear that CVD risk factors have worsened because of the COVID-19 pandemic – an alarming increase in unhealthy lifestyle behaviors (e.g., physical inactivity, poor diet, etc.) is at the forefront of this trend. The CVD risk factor crisis, or pandemic,⁸ was and is a global health emergency. We will not realize the full impact COVID-19 has had on CVD risk factors for some time but, if initial trends are allowed to go unabated and we accept a new unhealthy lifestyle baseline, the incidence and prevalence of CVD will most certainly rise in the years to come; 2) Populations, such as athletes, who are generally healthy and at low risk for CVD and cardiovascular dysfunction, have also been uniquely impacted by the COVID-19 pandemic, creating the need to establish evidence-based screening and return to play policies, as well as consider the implications on Long COVID in athletes; 3) Looking back to how we entered the COVID-19 pandemic, it is now clear the pump was primed for initial catastrophic outcomes before vaccines were an option and broadly utilized.^{2 , 3 , 13 , 14} Those individuals with unhealthy lifestyle behaviors and/or a known diagnosis of one or more chronic conditions, including CVD, were at the highest risk for hospitalization and poor outcomes with COVID-19 infection. This is particularly true for underserved communities and underrepresented individuals. These findings will hopefully serve as a wakeup call for the world, which, in truth, should have headed decades ago – healthy living medicine is essential for both chronic disease prevention and health resiliency in the event of viral infection; 4) Important cardiovascular services, including patient management by cardiologists and cardiac rehabilitation, were significantly impacted by COVID-19. While the initial impacts were certainly negative, opportunities arose to capitalize on the new pandemic-driven environment, including new models that allow for expansion of access to services; 5) If there is any hope of learning valuable lessons from the COVID-19 pandemic and reversing course in the context of CVD, public health initiatives and public policy will play instrumental roles; and 6) Three original research papers addressing various relevant topics including: a) stress cardiomyopathy outcomes with and without co-existing COVID-19 infection, demonstrating outcomes are worsened for this cardiovascular condition in patients also infected with COVID-19; b) the link between neighborhoods with low median household incomes and higher mortality in patients diagnosed with atrial fibrillation, once again bringing to light the social inequities we face in health – a prominent theme during the COVID-19 pandemic and one that must be urgently addressed; and c) exploring the public's current perception of the impact the Metaverse could have on mental health, with results indicating mixed views. Clearly, the world's usage of virtual technology will only increase moving forward and finding ways to leverage this platform to enhance, as opposed to harming, one's health is an important area of exploration.

To conclude, we are emerging from the bad dream known as the COVID-19 pandemic. The world is still yet to return to the normal we knew before the viral pandemic, but we have achieved a new post-pandemic normal that in many ways emulates pre-pandemic life (e.g., schools and fitness facilities are open, masking restrictions have been relaxed, etc.). In truth, we may never return to the pre-COVID-19 pandemic normal. The world should rightfully feel some sense of relief in awakening from the COVID-19 bad dream. However, our sense of relief should be short lived as we were, prior to COVID-19, and continue to be, in the unhealthy lifestyle – chronic disease bad dream. As illustrated by several reviews included in this edition, the current bad dream can and likely will become a nightmare if we do not act quickly; perhaps we are already living in a nightmare. It appears that it is safe to say there is a broad consensus on what needs to be done – create a proactive, preventive approach to health care that recognizes healthy living medicine as a core component.¹⁵ Creating such a system in the spirit of social justice, where all individuals have equal access, is an essential tenant. This is the only way we will truly awaken from the unhealthy lifestyle – chronic disease bad dream/nightmare we currently live in and prevent future bad dreams/nightmares created by the next viral pandemic – it's time to wake up from society's perpetual state of health-related bad dreams and set a new path forward.