By David Prince, MD | July 20, 2020

The most significant event of 2020 has been the COVID-19 pandemic that has swept the globe and halted Cardiopulmonary services throughout the United States. COVID-19 is a highly transmissible RNA virus that causes respiratory disease with the potential to cause significant medical complications in vulnerable populations especially those with cardiopulmonary disease. The pandemic has had multiple impacts on the cardiopulmonary rehabilitation community and our patients. It also presents opportunities for academic research within the cardiopulmonary rehabilitation community. 

Although severe interstitial pneumonia with acute respiratory distress syndrome and multi-organ failure is the most feared complication of COVID-19, individuals with underlying cardiovascular disease are at increased risk for thrombotic (clotting) and thromboembolic (travelling clots) disease. Indeed COVID-19 appears to disrupt hemostatic mechanisms that maintain the fine balance between clotting and bleeding in the blood and small blood vessels of the body. Active COVID-19 infection in the lungs can also create widespread inflammation and contribute to increased clotting throughout the body. Excessive clotting can occur in both the arterial and venous systems. There are currently numerous theories as to how COVID-19 infection may contribute to increased clotting in the body including immobility from illness, direct organ damage, triggering immune system overreaction, pulmonary micro-clots, and clotting cascades starting in the small blood vessels and spreading throughout the body.   

Nasal swabs and antibody testing are not the only lab tests that are relevant in COVID-19 infection. A number of different laboratory tests can be abnormal in active infection including mild thrombocytopenia (lower than normal platelets) as well as increased D-dimer levels (by products of dissolved clots.) Recent studies have suggested there may be a relationship between intensity of infection and prolonged prothrombin time (PT) as well as prolonged international normalized ratio (INR.) Both measures of how likely blood is to clot. Troponin levels can also be elevated in COVID-19 patients and may indicate myocardial infarction or just general inflammatory damage to the heart muscle.

Rehabilitation protocols for post COVID-19 survivors remain a work in progress with too little data to form definitive and final consensus from the academic community at this time. There are multiple opportunities for future research exploring the immediate as well as long term effects of COVID-19 infection and the benefits of the cardiopulmonary rehabilitation model for these patients – with or without pre-existing cardiopulmonary disease. Already reports of post-COVID syndromes that include generalized fatigue and likely decreased cardiopulmonary endurance have begun to be described. Although these patients would not be traditional candidates for cardiac or pulmonary programs, demonstrating the benefits of a supervised exercise program could potentially stimulate interest and research investigating the most effective protocols, types of exercise and exercise prescriptions in this growing population. Post-COVID syndrome research can potentially be divided into numerous areas of investigation some of which could include:

• Short and long term pulmonary function changes and response to pulmonary rehabilitation.
• Post-COVID cardiomyopathy and response to traditional heart failure rehabilitation.
• Generalized fatigue syndromes and various exercise training approaches within the cardiopulmonary rehabilitation model.
• Post-COVID ischemic syndromes and how the similarities or differences from traditional coronary artery disease models.
• The effect of supervised exercise programming on post-COVID lab abnormalities.
• The effect of enrolling post-COVID patients in cardiopulmonary rehabilitation/group exercise programs on their ability to return to work.

AACVPR members are among the most dedicated and creative health-care providers across all disciplines. Our unique training, focus on patient-centered care and decades long experience in maximizing limited resources through innovative practices positions every cardiopulmonary practitioner to make a unique contribution whether on the individual patient, community, research or national level. As in the chronic “pandemics” of coronary artery disease and chronic obstructive pulmonary disease the cardiopulmonary rehabilitation community will identify, study and refine the road to recovery for yet another global population in need of our expertise and compassionate care.