TTHealthWatch is a weekly podcast from Texas Tech. In it, Elizabeth Tracey, director of electronic media for Johns Hopkins Medicine in Baltimore, and Rick Lange, MD, president of the Texas Tech University Health Sciences Center in El Paso, look at the top medical stories of the week.
This week’s topics include COVID and wastewater, blood clots and COVID, treating mild hypertension in pregnancy, and use of a PCSK9 with statins after heart attack.
Program notes:
0:35 Wastewater and COVID
1:35 Broke down by age group also
2:35 People may not have symptoms
3:36 Blood clots, bleeding and COVID
4:37 Pulmonary embolism risk for 6 months
5:36 Prophylaxis not useful usually
6:32 Mild hypertension treatment in pregnancy
7:32 Enrolled women less than 23 weeks of pregnancy
8:33 Used to just wait it out
9:27 Treating people who’ve had a heart attack
10:30 Plaque less likely to rupture
11:29 Very expensive
12:05 End
Transcript:
Elizabeth Tracey: What can wastewater tell us about COVID infection?
Rick Lange, MD: Is there an increased risk of clotting or bleeding after COVID infection?
Elizabeth: Managing even mild high blood pressure during pregnancy and outcomes.
Rick: Benefits of combination therapy lowering cholesterol after you’ve had a heart attack.
Elizabeth: That’s what we’re talking about this week on TTHealthWatch, your weekly look at the medical headlines from Texas Tech University Health Sciences Center in El Paso. I’m Elizabeth Tracey, a Baltimore-based medical journalist.
Rick: And I’m Rick Lange, president of the Texas Tech University Health Sciences Center in El Paso, where I’m also the dean of the Paul L. Foster School of Medicine.
Elizabeth: Rick, starting with our COVID material, let’s turn first to JAMA. There is a research letter in here and I think it’s kind of an increasingly important field of public health inquiry — I’m predicting — especially following COVID. This is taking a look at levels of SARS-CoV-2 in wastewater and reported cases, hospitalizations, and vaccinations regarding COVID between March 2020 and November 2021 in Milan, Italy.
What they were looking at was the association between how much virus they actually found in urban wastewater and surveillance indicators of infection prevalence and severity. They correlated these things in a wastewater treatment plant that served about 50% of the Milan population. Then they looked at daily numbers of SARS-CoV-2 cases, hospitalizations, and an individual’s completion of the vaccination cycle. They even broke this down by age group.
They assumed a 15-day viral excretion for each positive or hospitalized individual. They basically found — it was really interesting — that this vaccination campaign, even though it reduced these other things, they still saw plenty of virus that was shed into the wastewater. Clearly, what that says is that vaccination is important with regard to helping out with the severity of infection, which is something that we think, of course, we already knew. But this clearly demonstrates that. And it also supports that wastewater surveillance, and this is why I said I think this is going to become an important public health strategy, is really a pretty good indicator of what’s happening with regard to all of these measures.
Rick: You and I are both aware that the standard way we assess the prevalence of infection is how many people report symptoms, positive cases, and how many people are hospitalized. That’s really how we’ve been marking the spread of COVID infection.
What this study suggests is OK, well, people that have been previously infected or have received vaccination may not develop symptoms, they may not be hospitalized, but they are still able to spread infection to other individuals. If we’re not using symptoms, how can we detect who they are? The wastewater study that you described suggests that’s how we can do that. Originally, I was skeptical. I thought, “Well, why do we need to look at wastewater? We just look at symptoms.” Well, in people that are asymptomatic, this is a preferred way of identifying that and getting ahead of subsequent spread of COVID.
Elizabeth: I think we are going to see a whole lot more of this, Rick, because I think we’re not going to be just monitoring things like viral loads. But there is plenty of other stuff that turns up in wastewater also, metabolites from different drugs that people are taking, all sorts of things.
Rick: As you mentioned, the CDC is going to recommend that we do this routinely. Now, there are some areas in the country where that can be done — for example, we are doing it here in El Paso — but there are many cities and metropolitan areas that are not yet set up to do this. But I think as you said it’s important and we are going to be doing this more in the future.
Elizabeth: Let’s turn to the BMJ and this is also something that’s important relative to COVID infection. Gosh, it seems like it increases the risk of clotting for folks even months after they have had the infection.
Rick: Elizabeth, we have previously reported on this in kind of small groups of patients. This is the largest study I’m aware of to date. It looks not only kind of around the time of infection, but even months afterwards, looking at common clotting disorders, developing a clot or a thrombus in the veins in your legs, or a clot in the lungs called a pulmonary embolism. Conversely, you can also have bleeding.
What these investigators did is they compared over a million people who tested positive for COVID infection in Sweden and compared them not only to themselves times before and after infection to see what the risk of clotting or bleeding disorders was, but also to 4 million people that hadn’t received the infection.
This is a huge study. What they discovered was that there is an increased risk of deep vein thrombosis for about 70 days after someone has had an infection. There is an increased risk of pulmonary embolism, 30-to-50-fold increased risk for up to 6 months, also an increased risk of bleeding disorders in the first 60 days after someone’s had a COVID infection.
Elizabeth: I think this is just tremendously concerning and it’s unclear to me exactly what’s actionable here.
Rick: Well, what is actionable is trying to prevent the clotting disorders. We know that individuals, by the way, that are sicker or in the hospital, or are in the ICU, are much more prone to develop these. We put them on prophylaxis. Before they’ve had a clot, we give them anticoagulants to prevent them, so that is actionable. The second thing is just realizing that this can occur because if someone has a pulmonary embolism and it goes untreated, it could be fatal. We want to recognize that this is an issue not just in the first week or two after infection, but up to 6 months after infection.
Elizabeth: Does this suggest to you that when people are discharged that they ought to be put on something to try to prevent this if they don’t experience clotting while they’re hospitalized?
Rick: Elizabeth, they have looked at prophylaxis in mild illness or in individuals that don’t have symptoms. It doesn’t appear to be particularly useful, so I wouldn’t recommend this routinely. We may need to target the high-risk group — those that have been hospitalized, and more importantly those who have been in the ICU. That is a group that may benefit from continued prophylaxis for a period of time.
Elizabeth: OK. Let’s just mention to our listeners that two of the COVID studies that did not make it through the cut this week, because we had so much other stuff we thought was so important, were the one in Nature Medicine taking a look at, “Well, all right, what does viral shedding look like in normal young people if we give them a viral challenge?” And the other one was, what’s the efficacy of the fourth dose, which was in the New England Journal of Medicine, in a big population in Israel. We just will refer you all to those journals if you’d like to follow those up.
Rick: Right. I wish we had time. There are really great studies to discuss. But let’s move on. Elizabeth, let’s talk about hypertension in pregnancy. You’re going to take the lead on this one.
Elizabeth: Indeed, and that’s also in the New England Journal of Medicine. The editorialist reminds us that the rate of hypertension during pregnancy has been rising inexorably over five decades. That’s in parallel with strongly associated covariance, maternal age greater than 35 years, and the presence of overweight or obesity. These factors were present in just shy of 56% of women who gave birth in 2019.
With that backdrop then, what about this mild chronic hypertension, which they define as a blood pressure of less than — and I’m guessing [less] than or equal to — 160 mmHg over 100 mmHg during pregnancy. They wanted to target a blood pressure of less than 140 over 90 and assess the incidents of adverse pregnancy outcomes, but not compromise fetal growth.
They enrolled all of these women who were pregnant with mild chronic hypertension, single babies, and gestational age of less than 23 weeks to receive antihypertensive meds that are recommended for use in pregnancy, or not.
They were taking a look, of course, at preeclampsia, medically indicated preterm birth less than 35 weeks’ gestation, and some other outcomes. It turns out that, yes, indeed, if you keep that blood pressure lower in that treatment group, 8% fewer women experienced preeclampsia and some of these other adverse outcomes were also avoided. This is looking like it’s a pretty good strategy.
Rick: Elizabeth, there is always concern about giving mothers who are pregnant medications that would adversely affect the mother and more importantly the fetus, especially if there is no benefit. What this study shows — again, a well-done study, 61 different sites, a large number of women — is that the medications are safe. They prevent complications we otherwise really weren’t concerned about because these women had “mild hypertension”. We used to just wait it out. There are 83,000 pregnant women in the U.S. annually that have hypertension before they become pregnant. The implications are enormous.
Elizabeth: Just to note, they did have over 1,200 women in each arm. I do want to point out though — again, back to [what] the editorialist says — this apparent reduction in the incidence of various measures of preeclampsia in the active treatment group is great. But these findings have not been observed in eight previous randomized trials, including a really big one known by the acronym of CHIPS. Before we get really wildly enthusiastic about this, I think it’s definitely something that needs to be repeated.
Rick: It does. This group is a little bit different than the other studies. About 50% of the women in this group were Blacks and we know that they have a higher incidence of having complications. Again, no complications associated with the medications, and a benefit.
Elizabeth: We’ll be seeing more about this. Let’s return then to JAMA and a study taking a look at treating people who have had a myocardial infarction.
Rick: People that have had a heart attack have manifestations of what we call a coronary atherosclerosis of cholesterol inside the arteries and they are more prone to developing another heart attack. We usually give intensive medical therapy to prevent another heart attack, and that includes high-intensity statins to lower their cholesterol.
But that’s only one of the medicines that can lower cholesterol. Once we’re given high-intensity statins, what if we can lower the cholesterol even more? We can do that by administering what are called PCSK9 inhibitors, alirocumab. It’s an injection that can be given twice a week. It’s more expensive than statins and it’s obviously a little bit more to administer. But in combination with statins, it can be very effective in lowering cholesterol. The question is, does that provide additional benefit in these patients?
The benefit they were looking for is, they looked for a regression of the coronary atherosclerosis. Did the cholesterol inside the vessel wall seem to decrease? Did the plaque seem to become more stable and have a thicker cap on it, which means it was less likely to rupture and cause another heart attack?
They took 300 individuals. All had a heart attack. All were on high-intensity statins. Half of them received placebo and half of them received the PCSK9 inhibitor.
They looked at the inside of their coronary arteries by three very sensitive techniques right after the heart attack and then again 1 year later. What had they discovered is those that received the PCSK9 inhibitor, first of all, they got their LDL cholesterol from 74 with statins down to 23 — the baseline was about 150-155 — and they were able to observe more atherosclerosis regression. The cholesterol plaque got smaller. The lipid content inside of it reduced and it developed a thicker cap as well.
All of those are surrogate measures indicating that really driving cholesterol down with these two different combination medical therapies was beneficial. Now, what we don’t know is whether that translates to decreased heart attacks in the future, so we need to do a larger study.
Elizabeth: No question that that’s the hard outcome. Of course, these things are breathtakingly expensive.
Rick: They are. If you have to pay for it out of pocket, it can be anywhere from $4,000, $6,000, $7,000, or $8,000 over the course of a year. For those that are Medicare Part D, they pay as little as $25 to $150 per month. But they are expensive and certainly more expensive than statins. Therefore, we want to make sure that not only is it effective, but really target the individuals that are most likely to receive the benefit.
Elizabeth: On that note then, that’s a look at this week’s medical headlines from Texas Tech. I’m Elizabeth Tracey.
Rick: I’m Rick Lange. Y’all listen up and make healthy choices.
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