Many argued throughout the pandemic that heart doctors should shut up about the novel virus or its mitigation policies. It was not our area. We should let the public health experts, epidemiologists, infectious disease and ICU doctors do the public thinking about SARS-CoV2.
Well, shutting up and waiting for others to act is not how the typical cardiologist rolls.
In the first weeks of the pandemic, after Northern Italy and New York, an email came to our group asking for volunteers for ICU work. None of us manage antibiotics or ventilators, yet nearly everyone sent quick replies-to-all that we were game. Grin, the overconfidence is quintessential cardiology. Expertise be damned, cardiologists run towards not away from a crisis.
Heroism, though, is not the reason I became so interested in the pandemic. (Electrophysiology is hardly a branch of medicine known for acute heroic care; we mostly do scheduled and elective procedures.)
I like to write, and to write anything interesting you need conflict.
The pandemic brought huge doses of conflict: it exposed the problems with medical evidence and, worse, its translation to the bedside; it forced us to confront the matter of expertise and dogma; it made us think about how humans make decisions; and finally, no one could deny the role of social media in making things better and worse.
These were all areas of conflict that I had spent the last decade thinking and writing about.
Three COVID-19 examples fit nicely with the theme of Stop and Think.
Early on during the pandemic, fear ran rampant. And if there is one thing in medicine that crushes good decisions it is fear.
Fear (that the patient would deteriorate abruptly and fear of infecting health care workers) led to the idea that patients with pneumonia due to SARS-CoV2 had to be intubated early and put on ventilators. I recall an ICU doctor telling me the story of a patient with low oxygen levels who was talking (comfortably) to his family on his cellphone. He was told to put down the phone as it was time to intubate him.
Early intubation went against the basic principles of respiratory physiology. It surely led to significant harm because patients had to be paralyzed and heavily sedated to breathe with the ventilator. We now accept that this was an error, but while it has happening, the response to a young doctor who spoke against ventilator protocols was to kick him out of the ICU.
Dr. Cameron Kyle-Sidell then took to YouTube to get his message out. He was early and correct; and social media helped improve patient care. I wonder now, in the era of tech companies blocking contrarian content, would Kyle-Sidell’s video have been taken down?
If you write about medicine, how can this story not interest you? The early intubation story shows how hard it is to go against accepted dogma.
The pandemic exposed the poor quality and broken incentives of medical evidence.
No better example exists than the fear that SARS-CoV2 had a special proclivity to harm the heart.
A July 2020 report published in the prominent journal JAMA-Cardiology started the madness. German researchers reported that almost 80% of patients recently recovered from COVID-19 had abnormalities on MRI scans of their heart. (Finally, cardiologists had a legit reason to speak publicly!)
The paper, however, was a mess. Methodological and arithmetic errors led to a corrected publication. And if you compared the scans of post-COVID-19 patients to only those matched by risk factors, there were no significant differences.
But none of that mattered. Nearly 400 news outlets ran stories with scary headlines. And now the flawed paper has more than 935,000 page views and 334 citations. Citations, of course, drive the main metric of journals, the impact factor.
JAMA-Cardiology soon published another scary paper; this series reported that 15% of athletes who had recovered from COVID-19 had abnormalities on cardiac MRI scans. The study had no control arm and only 26 athletes. It short, it too, was a mess.
I was part of a group that sent a letter to professional societies warning that this was flawed science and cardiac MRI scans should not be used in COVID-19 patients without symptoms.
None of that mattered. Hysteria had been created. College sports nearly stopped. Social media and regular media had amplified and ensconced the view that SARS-CoV2 posed a special danger to the heart.
But it wasn’t true.
Along with co-authors Vinay Prasad and Andrew Foy, we wrote in STAT News how study after study failed to replicate these early and flawed studies. We now know that SARS-CoV2 is like many viruses in that it can (rarely) cause inflammation of the heart, but it has no special proclivity to harm the heart.
Flawed studies, especially those that look back at data (so-called observational studies), were common during the pandemic. Along with a research team led by Penn State cardiologist, Andrew Foy, we published a review of top-cited papers during the pandemic, and found COVID-19 related articles were of much lower scientific quality than similarly cited pre-pandemic papers.
I see two main take-home points of this story: one was that too few smart people were skeptical of methodologically flawed science. The second, perhaps saddest message, is that those flawed studies will now help the journal enhance their status with a higher impact factor.
(Crazy is that scientific journals, the so-called arbiters of science, work on the same model as regular media—attention.)
Vaccine Induced Myocarditis
Two months ago I wrote a newsletter about the pros/cons of vaccinating young people against SARS-CoV2.
This was in May, before the news that mRNA vaccines can cause cardiac injury via excess inflammation. That observation changes everything. I have no idea why the mRNA vaccine would cause cardiac inflammation but it is clear that it can.
Before I write another word, I want to say that the incidence of myocarditis due to mRNA vaccine is very low.
But… here is the kicker…the risk that a young healthy person gets severely sick from SARS-CoV2 is also very low.
I, and my editor at theheart.org | Medscape Cardiology, spent many hours putting together this column on the matter of vaccine-induced myocarditis. It is free with an email. I hope you read it.
My main takes were that…
The highest incidence of myocarditis is after the second dose, and in males age 16-24.
While the myocarditis from vaccines mostly resolves, myocarditis is not a minor worry as a not zero number of young people can develop severe complications.
The incidence of vaccine-induced myocarditis in young people is in the same general (very low) range of getting severe COVID-19 in this age group.
The mRNA vaccines have been near miraculous for older adults, especially those with risk factors. This is important because, unlike other communicable diseases, people do not have to depend on others being vaccinated. The mRNA vaccines are so good, that any adult can simply take the free shots, and boom, they are protected from severe COVID-19.
Given these observations, my take was that parents and young adults should be allowed to consider their circumstances and use their judgement in their decision to take the vaccines now or wait.
The benefit of waiting is not so much waiting to get infected, but to wait for guidance on different strategies of vaccination, say single dose, vs use of the different vaccines in younger people, vs using lower doses or checking for natural immunity before vaccination.
I conclude the column by proposing that absolutism about vaccine decisions in this age group could diminish trust in public health messaging.
Why not lead with a more humble nuanced approach to vaccinating low-risk young people?
There were many more conflicts to learn from during the pandemic.
Let me know what you think about my take of these three.
Feel free to suggest other topics for future newsletters. In short, engage in the comments section. Even, or especially, if you think I am wrong.