"So the most seriously affected patients, over a third of them are diabetics and these were patients in the intensive care unit and the you know, the numbers are sobering. Over half the patients who make it to the ICU, are either still in the ICU or have died." - Dr. Sahil Parikh, MD
Shireen: Dr. Sahil Parikh is an interventional cardiologist focused on patient care research and teaching around the manifestations of atherosclerosis through the circulation. He has a large outpatient and inpatient practice and performs complex procedures in a population comprised of approximately 50% diabetic patients. He's passionate about advocacy for patients with vascular disease, and teaching the next generation. As an engineer, he aspires to help develop new technologies to improve care for his patients. Welcome, Dr. Parikh.
Parikh: Thanks very much. And it's nice to be on with you.
Shireen: Great. Dr. Parikh, I want to dive right in and first ask you what led you to a career in interventional cardiology?
Parikh: Well, it's sort of a long story. But I always was interested in the biomechanics of the body and in fact, when I was an undergraduate, I was trying to figure out if I wanted to do orthopedics, because I really liked how things in the body were mechanically connected. Pretty early on though, in undergrad, I got really interested in the fluid flow of the human body. In fact, I took a course entitled fluid flow in the human body and I got inspired by the engineering aspects of circulation. And it was really pretty much for my freshman year of college on that I got hooked on, on cardiovascular medicine, and specifically in interventions to modify the circulation. And that's really a natural connection to interventional cardiology. At the time, it was the early 90s and I was interested in research in the area and devices that would, would modify circulation, and one of the first devices of that kind was a stent. And I was involved in some of the earliest stent research, preclinical mostly in developing new designs of stents that could be used to, to open up blockages. And so to be honest, that was really from that experience, and my clinical interest that I've fast forwarded now, almost 30 years, and I'm still basically interested in stance and design of stance and, and drug delivery in the blood vessels and opening up blockages throughout the circulation. I've had a lot of experience, obviously, in between, in learning how to be a doctor, which I don't want to underestimate, but, but my fundamental passions remain the same.
Shireen: And so Dr. Park with that, and especially with your work that you're doing currently with COVID-19, I'd like to talk through some of that. What have you seen as a relationship between diabetes and the risk of complications from COVID-19? What does that relationship look like? And also, what do we know so far? And what needs to be further research about this relationship?
Parikh: Well, I mean, the, the COVID-19 experience here in New York has been really life changing. We've, as everybody knows, then probably the epicenter here in the United States. And we've seen 1000s of patients that our health system with the disorder. And so we've actually gotten a pretty up close and personal look at this illness, which, in its most severe forms is clearly a life threatening disease. It's got some unique attributes to it, you know, we perceive COVID-19 as a virus that affects primarily the lungs. But it turns out that it has significant manifestations outside of the lungs, in many of the organ systems, if not all of the organ systems of the body. Some of those are direct effects. Some are indirect effects, secondary to inflammation, and circulatory disturbances, which is where me and my team are involved. But the virus is clearly much more virulent than we would have otherwise expected from a Coronavirus, which is often associated with the common cold. Specifically, with respect to the patients that we're talking about the, those who have atherosclerosis, it's been pretty well demonstrated both in China and now in other parts of the world that patients with cardiovascular risk factors are at high risk for developing significant complications and potentially lethal complications of COVID-19. So, if one were to take, for example, our patient population at Columbia, we're at an academic medical center here in Manhattan with a, you know, over 700 beds, which at our peak, we are occupying approximately 600 plus beds with patients with COVID-19. And if you look at the statistics, you know, most of the patients are probably between the ages of 60 and above. Although there is a significant fraction probably 45% that are under 60. In our patient population at our hospital, it was almost three quarters Hispanic and 20 percent African Americans, a significant percentage of minorities. And most of the patients were overweight, with BMI greater than 30. With a significant number of patients, even over 35, or 40, the prevalence of comorbidities was significant. The most common was hypertension, about two thirds. But over a third of the patients had diabetes, and about 20% had chronic cardiac diseases, and a fewer, a few percentage had chronic kidney disease. So these are patients who are at risk for cardiovascular complications, and a big percentage of them are diabetic patients. The interesting thing was that this is really looking at as a snapshot of the patients that were in the intensive care unit. So the most seriously affected patients, over a third of them are diabetics and these were patients in the intensive care unit and the, you know, the numbers are sobering. Over half the patients who make it to the ICU, are either still in the ICU or have died and so their mortality, we expect, it's going to be around 50%. So once you get sick and get into the ICU, your chances of survival, even with an excellent Medical Center, supporting you with all of the tools we have at our disposal. It's, it's a high mortality, so it's very sobering. In the data, the demographic data were published in The Lancet by our group in pulmonary critical care. So if people want the reference, we can provide that, but I think it sort of hammers home the fact that ethnic minorities are over represented, it seems relative to their, their population density. And more importantly, the preponderance of the data suggests that patients with cardiovascular comorbidities or risk factors, particularly diabetes, are really high risk for critical illness.
Shireen: And so what is it about diabetes or even a chronic illness overall, that, that makes that risk of complications, you know, exacerbated with, you know, with COVID-19?
Parikh: I mean, I think the short answer, if I'm being truthful, is that we don't really know yet. There's a number of speculated mechanisms. But those are highly theoretical, there isn't really a good understanding. I can say more broadly, with respect to cardiovascular complications, it's pretty clear, like I said that there are direct and indirect effects. The direct effects are potentially related to two specific mechanisms. One is inflammation of the heart muscle itself, a condition called microcode itis, which can result in reduction of circulatory capacity of the heart. And then there's also this proinflammatory state, which is almost not previously been described, where patients develop very, very intense inflammation, with an immune response that winds up being injurious. And it promotes thrombosis, and also organ dysfunction throughout the circulation. And there is seemingly, at least in the pre COVID era, literature that suggests that inflammation, especially in the diabetic substrate increases the risk of heart attack and other thrombotic events, including venous clotting. And so what we're seeing in these patients is really intense inflammation, higher than expected amounts of thrombotic complications, so clots in their blood vessels, more so in the veins than in the arteries. And so the implications for that are deep vein thrombosis, and potential pulmonary ambalaj, which are clots that go into the lung and reduce the ability for the body to get oxygen and circulate it. So I think those are, those are serious considerations that may be related and or exacerbated in the diabetic patient.
Shireen: So with that, what, what kind of research, what kind of retrospective research is being done with the data that's being collected right now? And then how will that help us for a possible future wave in the late fall?
Parikh: Yeah, so I mean, I think that we are intensely involved in research, as you can imagine. Many, 1000 patients have been admitted to our health center, and our sister hospitals, and, frankly, all of the community of academic researchers, irrespective of what flag they fly, you know, which institution they're from those people, as scientists are working very hard to, to, you know, actively investigate all of the things that we can. So, for example, some of the demographics that I've given you are from a database that's been compiled here at Columbia that's continually expanding and every single day, we are hearing about new analyses that are being mined out of these data. And, you know, we're looking for example, are there correlations between specific drug use drugs that are used, for example, patients that are previously on certain antihypertensives? Oral hypoglycemics for diabetic patients and statins for cholesterol, are those drugs protective in any way? Are there any molecular mechanisms that one could postulate that might be impacted by those pathways? There's obviously the prospective arms of these data as well and those prospective studies are looking at individual manipulations. For example, you've probably heard of remdesivir and other antiviral drugs that have been studied for the treatment of COVID-19. There, they're looking at the subgroups of those studies that have diabetic patients enriched to see if there's an enhanced effector efficacy in that population, or, you know, being truthful and honest, is there less of an effect in those patients. Similarly, there's anti inflammatory drugs, aisle six inhibitors and others that have been studied. And we're looking at the diabetic substrate as a serious and important subgroup to see if there's a differential effect in that population. And then, you know, I think that we talked a little bit about blood clotting and so I'm leading a clinical trial that's looking at different doses of blood thinners that are used for hospitalized patients, that might, in fact, be protective, and help reduce some of these adverse effects of COVID-19 with respect to clotting. So that trial is ongoing in our ICU is right now it's enrolling slowly only because we don't have as many critical care patients as we did four weeks ago, you know, where this is the beginning of June, at the beginning of April and the end of March, really, we were at the height of the surge, when patients were, you know, literally being admitted to the ICU and record numbers, we fortunately come significantly down from there. But we're still seeing a steady stream of patients, and we're admitting them to the ICU is not infrequently, unfortunately. And so we're going to get answers to some of these questions, hopefully, over the course of the next several months and have some information that can hopefully inform our practices, should there be another spike of cases coming fall?
Shireen: So we know that and you mentioned this just a little bit ago. So we know that minority communities are disproportionately impacted by diabetes. So emerging data suggests a disproportionate burden of illness, and even death from COVID-19 among these racial and ethnic minority groups, why is that? What is that relationship? And then how does socio economic, you know, socio economic background play a role here?
Parikh: Well, I mean, I think that there's a number of mechanisms that can be speculated. However, as, as with everything in this illness, there's very little solid, confirmed evidence, you know, there are pockets of research that have potentially suggested mechanisms. But I would be reluctant to sort of go out on a limb and suggest that there's any known mechanism, I think, clearly health status, and underlying health literacy really are contributory. I can, you know, not that anecdote would make for data, but I have a number of my own patients who live in the community around Colombia. And these patients are mostly people of color. Many are immigrants and they frequently have access to care of the kind we can deliver. However, their overall health literacy is not very high and it seems that, for example, the concepts of social distancing are very, very difficult when you live in a joint family, with multiple heads under one roof. And the younger members of the family are obviously generally essential workers and they're out there in the community working and getting exposed. And those exposures are brought home, and often affect the most vulnerable amongst us, many of whom are older, diabetic, and frequently with other comorbid illnesses, including hypertension or under Frank coronary disease. And so, you know, we're seeing that in these populations, specifically, in neighborhoods like Washington Heights, where my medical center is located, that these factors may be in play, if one were to do a zip code analysis of New York. Some of the most hard hit areas are also very densely populated and are of lower socioeconomic status, based on the demographic data that are available. And they include areas in the boroughs of New York, such as in Queens, and other places that have been in the lay press because of their heavy burden of illness and you And it doesn't have to be anything more than a phone call. And I know that's probably not easy for everybody. But even a telephone call can get you connected with a health care provider who can over the phone, help triage your symptoms, and give you some meaningful advice for how you should proceed. And if you're encouraged to go to seek care, please don't be afraid. While there is risk of infection, that will never be zero, the risk is close to zero. And we looked at our hospital data for patients who present without COVID-19 during this pandemic, and were kept on what we call COVID, negative floors. And the risk of infection was essentially zero. I think there was one patient who changed from negative to positive in the hospital. And it wasn't clear if they had already been exposed in the community, because there were contexts in their family that were ill. So you know, I think we were able to with protective equipment in the P PE, or personal protective equipment that, that we're offering patients and also for the providers. Most importantly, we've done a very good job. Even though it doesn't always sound like it, we've done a good job with protecting people from getting sick in the hospital. So again, I can't I can't say it strongly enough. If you feel sick, please, please seek care. And let us help you. Because it would be even more tragic if we let the virus beat us by preventing us from accessing the care that's available to us.
Shireen: So we say Dr. Parikh toward the end of the episode, I I'd love to let our listeners in part with how they can learn more about your work, and how perhaps they can connect with you after this podcast.
Parikh: Yeah, certainly, I think we'd be delighted to be accessible, I think you're going to post some social media links and you can reach us through, through Twitter and LinkedIn. Certainly, you can reach us at New York Presbyterian, our direct telephone line is, is area code 212-305-7060. And that'll be answered by one of our receptionists. And, of course, you know, we are out there, and we have email and, and other data that's posted on the websites. So you can reach us in any way that you feel appropriate. I think the most important thing, I always say it in any of these kinds of discussions is that that patients should seek care locally and talk to their doctors, your doctor will have we will be very well versed, I'm sure in the implications of COVID-19 for you as a patient, and will more importantly know you better. And we certainly are available to answer questions and to help provide guidance, but your doctor is your best resource as always.
Shireen: Great. So with that, Dr. Parikh I want to thank you so much for coming on the endless podcasts, you know, giving us all these insights and also sharing very valuable information and very timely for for what's going on out there. Thanks.
Parikh: Thanks for having me.