GUIDANCE FOR HEALTHCARE PROFESSIONALS
In view of the COVID-19 pandemic and its effect on outpatient clinics and diagnostic investigations, there needs to be a re-evaluation of the way we manage patients with heart valve disease. These tables below are designed to help guide clinicians on outpatient management of heart valve disease in the current environment, when clinic slots and diagnostic investigations remain limited in most parts of the country.
GUIDANCE FOR PATIENTS
A position statement from the British Heart Valve Society
Am I high risk?
People with heart disease are at higher risk from Covid-19 but no information specifically for valve disease exists. It is likely that mild or moderate valve disease does not increase the risk. This includes people with bicuspid valves and mitral prolapse with valves that function well. However, it is likely that severe valve disease can increase risk particularly if it is associated with symptoms (usually breathlessness or chest tightness on exertion) or heart failure. You may also be at higher risk if you have had surgery for heart valve disease in the past 3 months. If your surgery was longer ago than this, then you are not expected to be at higher risk unless the repaired or replaced valve is not working normally or your heart is not pumping blood normally (i.e. left ventricular function is reduced).
What should I do if I develop symptoms from the valve disease?
If you develop new and especially progressive breathlessness or chest tightness on exertion, you should contact your GP or the cardiologist who usually supervises your care. People with very severe valve disease may still need surgery despite the current covid-19 epidemic. This is a judgement for your specialist and the arrangements for care will vary depending on local arrangements.
I was scheduled to have heart valve surgery and have now been told it will be delayed. Should I be worried?
Although many planned / scheduled operations will be delayed by the coronavirus outbreak, it is important for you to be reassured that there will always be provision in the NHS to provide urgent or life-threatening operations for patients that need it. If your planned procedure has been delayed, you should monitor any symptoms and let the hospital team know if you experience any deterioration (e.g. increasing breathlessness on exertion, new chest pain on exertion, or dizziness on exertion).
I have a metallic / mechanical heart valve and it is difficult to get INR checks at present. Should I switch from warfarin to heparin injections?
The reasoning behind this question is the hope of avoiding visits to the GP or hospital for blood tests to check the INR. However, if you are taking warfarin because of a mechanical replacement valve, heparin injections are not as good as warfarin medication as there is a higher risk of developing blood clots on the valve. Therefore, continuing on warfarin is the best option for you if this is possible. Some anticoagulation clinics are suggesting home testing where there is adequate back-up from district nurses. Other clinics are sending transport to avoid patients needing to use public transport. Most clinics are trying to space out appointments to maintain ‘social distancing’. You should only switch to heparin injections if INR testing is proving very challenging and this is the advice of your local cardiologist after discussing with you the risks and benefits of this change.
If I develop a fever, do I need to think of infective endocarditis?
The main symptoms of Covid-19 are fever, a dry cough and breathlessness. Some people experience diarrhoea and some have loss of taste. Other than the fever these symptoms are not typical of infective endocarditis. Currently Covid-19 is all too common while infective endocarditis is still uncommon. This means that a fever is more likely to be caused by Covid-19. If, however, you are severely unwell you need to phone 111 whatever the cause. If you have a more minor fever lasting longer than a week you should ask your GP for advice especially if you have severe gum disease or an untreated tooth infection.
Should I stop any of my medications?
There have been questions over whether angiotensin blocking medicines (e.g. “ACE inhibitors”) might worsen the effects of Covid-19. However, there is also some evidence that these drugs may be protective. All major international cardiac authorities agree that you should not stop angiotensin converting enzyme inhibiting drugs or angiotensin receptor blockers. No other drug has attracted concern to date.
Finally, the British Heart Valve Society would like to re-iterate that the best way to stay safe during this viral pandemic is to follow the Government’s and NHS England’s advice:
- Wash your hands often, using soap and water for at least 20 seconds. Use an alcohol-based hand gel if soap and water are not available.
- Avoid touching your eyes, nose, and mouth
- Avoid close contact with people who are sick
- If you feel unwell, stay at home, do not attend work or school