Spectrum of Cardiac Manifestations in COVID-19.pptx
- 1. DR SHARAT M VIJAPUR CONSULTANT INTERVENTIONAL CARDIOLOGIST
- 3. Stages Pathogenesis Symptoms Signs Proposed Therapeutic Strategies Based on Limited Data 1 Viral response/early infection Constitutional Respiratory Gastrointestinal Mild leukopaenia, lymphopenia. Elevated PT, D dimer, LDH, CRP; ferritin; IL6.Procalcitonin may be normal Antimicrobial therapy Reduce Immunosuppressan ts if needed 2 Inflammatory phase/pulmonary phase Shortness of breath Hypoxia: PaO2/FiO2 ratio < 300 Increasing Inflammatory markers including cardiac biomarkers (Troponin, BNP) Abnormal CT chest Supportive care. Restrictive IV fluid strategy. Antimicrobials, Immunotherapy per ID. 3 Hyperinflammatory phase/Cytokine release storm ARDS SIRS, Sepsis Cardiac failure Multiorgan dysfunction, Shock, DIC Markedly elevated inflammatory markers, cardiac biomarkers Antimicrobial, Immunotherapy per ID. Supportive care including vasoactive drips if indicated. Table 1 Stages of COVID-19 infection.
- 4. 1. SARS-CoV-2 is an enveloped, positive-sense single-stranded RNA virus.9 SARS-CoV-2 and other similar coronaviruses use the ACE 2 (ACE2) protein for ligand binding before entering the cell via receptor-mediated endocytosis. 2. More than 7.5% of myocardial cells have positive ACE2 expression, based on single-cell RNA sequencing, which could mediate SARS-CoV-2 entry into cardiomyocytes and cause direct cardiotoxicity.
- 5. Possible mechanisms of cardiovascular injury due to COVID-19. Yu Kang et al. Heart 2020;106:1132-1141 Copyright © BMJ Publishing Group Ltd & British Cardiovascular Society. All rights reserved.
- 8. Chest PainKey points• Chest pain and breathlessness is a frequent symptom inCOVID- 19infection; Chronic and acute coronary syndrome presentations can be associated with respiratory symptoms. The symptom of chest pain or tightness is common in patients with activeCOVID-19infection. It is usually poorly localized and may be associated with breathlessness due to the underlying pneumonia. Electrocardiographic changes suggestive of myocardial ischaemia. Where biomarkers are altered, Type 2 myocardial infarction (MI) may be suggested
- 9. The same ECG diagnostic criteria for cardiac conditions apply in patients affected by the SARS- CoV-2 infection and in the general population.
- 10. Prolonged QTc • monitoring at least daily QT assessment •• Monitor electrolytes; Keep K >4.5, Mg >2.2 •• Monitor for QT prolongation if on QT prolonging medications •• QTc=QT/√RR interval (in sec, Bazett correction). QTc will approximately be equal to QT if HR 60–70 bpm. • Key thresholds:• If QTc ≥470 ms in males and ≥480 ms females but <500 ms: close surveillance and stop QT prolonging medications •• If QTc >500ms or >550 ms with BBB or increase in QTc >60 ms after drug initiation: place pacer pads, stop QT prolonging medication and maintain HR >80 bpm with isoproterenol or dobutamine.
- 12. Polymorphic VT Sustained VT Ventricular fibrillation Torsades de Pointes (TdP) •• Amiodarone bolus 150 mg IV Isoproterenol + Lidocaine or temporary pacing if bradycardia induced torsade de pointes. •• Monitor electrolytes: Keep K >4.5, Mg>2.2 •• VT: Amiodarone 150 mg bolus then infusion 1 mg/min if QTc<450 ms (300 mg IV i; Avoid amiodarone if QTc markedly prolonged. •• VT: Lidocaine if QTc>550 ms: bolus 75–100 mg then infusion 0.5–2 mg/min, avoid if poor hepatic function or severe heart failure •• TdP/polymorphic VT: Maintain heart rate of >80 bpm (may need beta agonist such as dobutamine, isoproterenol or epinephrine; transvenous pacing). •• Magnesium IV 2–4 gm for Torsade de Pointes ••
- 13. Do not perform routine cardiac imaging in patients with suspected or confirmed COVID-19. Perform imaging studies in patients with suspected or confirmed COVID-19 only if the management is likely to be impacted by imaging results. The imaging protocols should be kept as short as possible. Non-urgent or elective cardiac imaging should not be performed routinely in patients with suspected or confirmed COVID-19 infection. Accordingly, non-urgent or elective exams should be postponed until the COVID-19 infection has ceased
- 14. Cardiac troponin T/I andBNP/NT-proBNPconcentrations should be interpreted as quantitative variables; In patients hospitalized withCOVID-19, mild elevations in cardiac troponin T/Iand/orBNP/NT-proBNPconcentrations are in general the result of pre-existing cardiac disease and/or the acute injury/stress related toCOVID-19;
- 15. Marked elevations in cardiac troponin T/I concentrations (e.g. > 5 times theULN) may indicate the presence of shock as part ofCOVID-19, severe respiratory failure, tachycardia, systemic hypoxaemia, myocarditis, Takotsubo syndrome orT1MI triggered byCOVID-19. In the absence of symptoms or ECGchanges suggestive of T1MI, echocardiography should be considered in order to diagnose the underlying cause.
- 16. Severe COVID-19 disease is associated with features of disseminated intravascular coagulation (DIC) and hypercoagulable states which can manifest as venous thromboembolism (VTE) and/or microthrombosis. •Critically ill patients with COVID-19 have been reported to have a VTE incidence rate around 30% which is significantly higher than non-COVID-19 critically ill populations
- 20. There is currently no evidence to suggest that hypertension per se is an independent risk factor for severe complications or death from COVID-19 infection; Despite much speculation, evidence from a recently published series of observational cohort studies suggests that prior or current treatment with ACEIs or ARBs does not increase the risk of COVID-19 infection when compared to the risk in patients taking other antihypertensive drugs
- 24. Cardiovascular concerns Treatment considerations STEMI and NSTEMI Primary PCI vs thrombolytics Myocardial injury Worse prognosis, monitoring rising trends Hypercoaulable state Thromboprophylaxis ACEI or ARB use Continue treatment currently, await further studies HCQ, CQ and/or azithromycin use QTc monitoring, avoid other QTc prolonging drugs Immunosupression/Immunomodulation Maybe helpful in selected patients with cytokine storm MCS IABP and VA ECMO might be used for support in cardiogenic shock Cardiovascular considerations in treatment
- 25. THANK YOU
Editor's Notes
- #6: Possible mechanisms of cardiovascular injury due to COVID-19. DIC, disseminated intravascular coagulation; SARS-CoV-2, severe acute respiratory syndrome coronavirus 2.