The European Society of Cardiology (ESC) consulted with colleagues across Europe, to make clarifications in the coronavirus crisis, also known as COVID-19 pandemic.1 Dr. Barbara Casadei2, ESC’s current president, reminds us all that
We must not forget the needs of patients with cardiovascular disease.”– Dr. Barbara Casadei, President of the European Society of Cardiology
Hereby we provide a summary of the recommendations provided by experts across Europe on how to manage cardiovascular disease patients in the current COVID-19 pandemic.
Cardiac complications in COVID-19
Dr. Magdalena Lettino, past president of the Acute Cardiovascular Care Association of the UK, observes that managing “general chest pain” poses a great challenge.3 It is difficult to discern if the chest pain is cardiogenic, or due to upper respiratory airway irritation. Her facility, San Gerardo Hospital, in Monza, Italy, has not seen a lot of ACS in COVID-19 patients.
Dr. Alaide Chieffo, Interventional Cardiologist at San Raffaele Scientific Institute in Milan, Italy, notes delays in the management of patients with STEMI.4 She speculates that this is because patients are reluctant to attend the hospital for fear of exposure to the virus; additionally, ambulance transport have been delayed due to the overload of COVID-19 related calls. Of 33 patients with COVID-19 who underwent urgent coronary angiography in Lombardy, Dr. Chieffo reports that:
- All patients had ischemic ECG changes, with 45.5% showing ST-segment elevation
- 60.6% had a LVEF < 50%
- 81.8% had elevated troponin
- 60% had no culprit lesion
Dr. Chieffo recommends following ESC guidelines for patients with both ACS and COVID-19. Primary PCI remains the reperfusion therapy of choice if feasible within the time frames as recommended by the ESC, and if performed in facilities approved for the treatment of COVID-19 patients. If the target time cannot be met, consider fibrinolysis. Regarding patients with non-STEMI:
- If clinically stable: utilize a conservative strategy with optimal medical therapy and monitoring, as opposed to early invasive management
- If clinically unstable, proceed with early invasive management, in accordance with ESC guidelines
Dr. Alida Caforio, Chair of Myocarditis and Cardiomyopathy Registry of the European Society of Cardiology, discusses cardiac complications in COVID-19.5 Four mechanisms of cardiac injury in COVID-19 are proposed:
- ACE2-mediated direct damage
- Hypoxia induced myocardial injury
- Cardiac microvascular damage
- Systemic inflammatory response syndrome
Dr. Cafario emphasizes that none of these has been proven. She notes that arrhythmia is not a common feature of COVID-19 disease, and there is no evidence of myocarditis in COVID-19 either. Although patients may have elevated troponin levels, this finding is not equivalent to myocarditis or acute MI. Myocarditis must be defined using ESC diagnostic criteria, including endomyocardial biopsy. Her team follows ESC guidelines and uses steroids only in biopsy-proven virus negative non-COVID-19 patients. If the patient is COVID-19 positive, steroids are contraindicated, as they may limit viral clearance. Currently there are no evidence based treatments for cardiac complications of COVID-19. Randomized controlled trials are needed.
COVID-19 and cardiovascular drugs
Pharmacologist Garret FitzGerald6 from University of Pennsylvania affirms:
- There is no evidence to discontinue anti-inflammatory agents
- There is no evidence at this time to discontinue ACE inhibitors, but more data is needed
- There is no evidence that chloroquine is an effective treatment for, or prophylaxis against, COVID-19. Furthermore, chloroquine can cause arrythmias and GI disturbances. FitzGerald recommends against using chloroquine until more research is done.
Diagnostic imaging in COVID-19
Dr. Antoine Khalil7, President of the French Society of Thoracic Imaging and the head of Radiology at Hôpital Bichat in Paris, provides this information regarding chest X-ray and CT in COVID-19.
- Changes on chest X-ray are seen within 4-5 days of symptom onset
- Typical chest X-ray findings are bilateral peripheral consolidation or multifocal grand glass opacities, peaking 10-12 days after symptom onset
- Chest X-ray has a lower sensitivity than PCR testing
- Changes are seen more clearly on CT than on chest X-ray
- Perform CT on day 7 and again on day 14, to monitor progression
- The extent of parenchymal lesions correlates with oxygen requirements, the evolution towards resuscitation, and mechanical ventilation. With extensive consolidation, expect that the patient will be in the ICU within 48-72 hours
- If symptomatology suddenly worsens, monitor for pulmonary embolism (angio CT)
- Perform chest X-ray for all non-transportable patients, and CT for all others, especially at initial assessment
- Don’t miss TB and bacterial pneumonia
Clinical presentation of respiratory failure
Jose Luis Zamorano8, a Cardiologist at Hospital Ramón y Cajal in Madrid, Spain, relates that only 10-20% of patients with COVID-19 will require intubation and ventilation; this need typically arises 5-7 days following admission. Chest X-ray findings do not predict clinical course. There are no reliable predictors of the need for ventilation; Dr. Zamorano recommends monitoring saturated O2 levels.
Dr. Tobias Welte9, Professor of Pulmonology and Infectious Diseases in Hannover University School of Medicine, shares these valuable insights:
- Prior to intubation, high-flow oxygen therapy (HFOT) is preferred over non-invasive ventilation (NIV) due to the increased risk of aerosol spread
- Risks for deterioration: elevated levels of CRP, LDH, ferritin, lymphocytopenia
- Intubate and ventilate if there is progressing hypoxemia despite HFOT, extrapulmonary organ failure, and dizziness/delirium
- Initiate moderate PEEP at 8-10 mmHg. Proning for 48 hours at a time is helpful
- Fluid resuscitation is seldom necessary; a negative water balance will help to decrease extravascular water
- Recovery is “wavy,” with periods of improvement and deterioration, making weaning difficult. Early tracheostomy is favored.
- Mean time on ventilator is 14 days.
What have we learned
Although cases of COVID-19 are currently dropping in many places we must stay prepared for a potential increase in cases in the fall and winter. Dr. Susanna Price10, President of the Acute Cardiovascular Care Association and practising out of the Royal Brompton in London, UK, urges the following:
- Don’t forget non-COVID-19 patients!
- Double your order of PPE; secure >1 supplier, and secure it
- Practice safe donning and doffing of PPE
- Isolate and reduce non-essential staff
- Develop COVID-19-positive SOP’s and drills, especially regarding patient transport and the minimisation of aerosolization
- Maximize skills by forming teams. Have dedicated teams for intubation and ventilation, proning, etc.
- Establish a Command Control structure and have regular situation reports.
- This is a marathon, not a sprint! Be prepared to adapt.
- Assume that all patients have COVID-19 until proven otherwise
Dr. Casadei states that more people will die of cardiovascular disease than of COVID-19 and encourages us that:
We must continue to save the lives we know how to save.– Dr. Barbara Casadei, President of the European Society of Cardiology
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Author: Kelly Schoonderwoerd