COVID-19-associated heart failure: Difference between revisions

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{{CMG}}; {{AE}}{{Mitra}}{{MC}}
{{CMG}}; {{AE}}{{Mitra}}{{MC}}


{{SK}}  
{{SK}} coronavirus disease-19, coronavirus disease 2019, SARS-CoV-2, COVID-19, 2019-nCoV, 2019 novel coronavirus, acute heart failure, de novo acute heart failure, chronic heart failure, acute decompensated heart failure, HFrEF, HFpEF, heart failure with reduced ejection fraction, heart failure with preserved ejection fraction


==Overview==
==Overview==


*Both [[de novo acute heart failure]] and [[acute decompensation of chronic heart failure]] can occur in patients with [[COVID-19]].
*Both de novo [[acute heart failure]] and acute decompensation of [[chronic heart failure]] can occur in patients with [[COVID-19]].
*Patients with [[chronic heart failure]] may be at higher risk of developing severe [[COVID-19]] infection due to the advanced age and the presence of multiple comorbidities.
*Patients with [[chronic heart failure]] may be at higher risk of developing severe [[COVID-19]] infection due to the advanced age and the presence of multiple comorbidities.


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***Heart failure with reduced ejection fraction (HFrEF) vs heart failure with mid-range ejection fraction (HFmrEF) and heart failure with preserved ejection fraction (HFpEF),   
***Heart failure with reduced ejection fraction (HFrEF) vs heart failure with mid-range ejection fraction (HFmrEF) and heart failure with preserved ejection fraction (HFpEF),   
**The severity of heart failure (i.e., the New York Heart Association Class I-IV)
**The severity of heart failure (i.e., the New York Heart Association Class I-IV)
**The stage of congestive heart failure (i.e., AHA Class A,B,C,D)
**The stage of congestive heart failure (i.e., AHA Class A, B, C, D)


*Acute heart failure has two forms:
*Acute heart failure has two forms:
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**Impaired myocardial relaxation resulting in [[diastolic dysfunction]] [i.e., [[Heart failure with preserved ejection fraction (HFpEF)]] ]
**Impaired myocardial relaxation resulting in [[diastolic dysfunction]] [i.e., [[Heart failure with preserved ejection fraction (HFpEF)]] ]
**Right-sided heart failure, secondary to [[pulmonary hypertension]] caused by hypoxia and [[acute respiratory distress syndrome]] (ARDS)
**Right-sided heart failure, secondary to [[pulmonary hypertension]] caused by hypoxia and [[acute respiratory distress syndrome]] (ARDS)


==Causes==
==Causes==
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**Acute pulmonary embolism
**Acute pulmonary embolism
**Pericardial tamponade
**Pericardial tamponade
*Iatrogenic




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==Risk Factors==
==Risk Factors==
 
*
 
*


==Screening==
==Screening==
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==Natural History, Complications, and Prognosis==
==Natural History, Complications, and Prognosis==
 
*COVID-19 patients with chronic heart failure are more likely to develop severe forms of the disease.
*COVID-19 patients who develop acute heart failure (either de novo AHF or ADHF) have worse outcomes.
*Acute heart failure in COVID-19 may progress to cardiogenic shock.
 
==Diagnosis==
==Diagnosis==
===Diagnostic Study of Choice===
===Diagnostic Study of Choice===
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**[[Left bundle branch block]]
**[[Left bundle branch block]]
**[[Poor R progression]]
**[[Poor R progression]]
**ST-T changes
**[[ST-T changes]]


===X-ray===
===X-ray===

Revision as of 21:29, 29 June 2020

For COVID-19 frequently asked inpatient questions, click here
For COVID-19 frequently asked outpatient questions, click here

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Mitra Chitsazan, M.D.[2]Mandana Chitsazan, M.D. [3]

Synonyms and keywords: coronavirus disease-19, coronavirus disease 2019, SARS-CoV-2, COVID-19, 2019-nCoV, 2019 novel coronavirus, acute heart failure, de novo acute heart failure, chronic heart failure, acute decompensated heart failure, HFrEF, HFpEF, heart failure with reduced ejection fraction, heart failure with preserved ejection fraction

Overview

Historical perspective

Classification

  • Heart Failure in COVID-19 may be classified similarly to heart failure from other causes.
  • In general, HF can be classified based on:
    • The pathophysiology of heart failure:
      • systolic vs diastolic
      • left-sided vs right-sided
    • The duration of symptoms:
      • acute vs chronic
    • The underlying physiology based on left ventricular ejection fraction (LVEF):
      • Heart failure with reduced ejection fraction (HFrEF) vs heart failure with mid-range ejection fraction (HFmrEF) and heart failure with preserved ejection fraction (HFpEF),
    • The severity of heart failure (i.e., the New York Heart Association Class I-IV)
    • The stage of congestive heart failure (i.e., AHA Class A, B, C, D)
  • Acute heart failure has two forms:
    • Newly-arisen (“de novo”) acute heart failure
    • Acutely decompensated chronic heart failure (ADCHF)

Pathophysiology

  • Presumed pathophysiologic mechanisms for the development of new or decompensated heart failure in patients with COVID-19 include:[1] [2] [3] [4] [5]


Causes

  • Acute myocardial injury
  • Acute coronary syndromes
  • Myocarditis
  • Hypertensive crisis
  • Arrhythmias: Tachycardia or severe bradycardia
  • Stress-induced cardiomyopathy
  • Circulatory failure:
    • Acute pulmonary embolism
    • Pericardial tamponade
  • Iatrogenic


Differentiating ((COVID-19 associated heart failure)) from other Diseases

In patients with COVID-19 infection, acute heart failure should be differentiated from other diseases presenting with dyspnea and/or tachypnea. The differentials include the following:

  • Pneumonia
  • ARDS
  • Myocarditis/pericarditis
  • Acute pulmonary embolism


Epidemiology and Demographics

  • In one study, acute heart failure was seen in 4.1% of patients with acute cardiac injury.
  • In a retrospective study on study 191 COVID-19 patients in Wuhan, China, the incidence of heart failure was 23% (52% in non-survivors vs 12% in survivors).

Risk Factors

Screening

  • There is insufficient evidence to recommend routine screening for heart failure in COVID-19 patients.
  • Routine measurement of natriuretic peptides and/or cardiac troponins have not been recommended in the absence of a high index of suspicion for HF on the clinical grounds.

Natural History, Complications, and Prognosis

  • COVID-19 patients with chronic heart failure are more likely to develop severe forms of the disease.
  • COVID-19 patients who develop acute heart failure (either de novo AHF or ADHF) have worse outcomes.
  • Acute heart failure in COVID-19 may progress to cardiogenic shock.

Diagnosis

Diagnostic Study of Choice

History and Symptoms

  • The most common symptoms of acute heart failure in COVID-19 patients are:
    • New or worsening dyspnea: may overlap with dyspnea caused by concomitant respiratory involvement and ARDS due to COVID-19
    • Peripheral edema
    • Confusion and altered mentation
    • Orthopnea
    • Palpitations
    • Paroxysmal nocturnal dyspnea
    • Cool extremities
    • Cyanosis
    • Dizziness
    • Syncope
    • Fatigue
    • Hemoptysis

Physical Examination

  • Physical examination of patients with acute heart failure is usually remarkable for:
    • Crackles on auscultation
    • Distended jugular veins
    • Lower extremity edema

Laboratory Findings

  • Cardiac Troponins:
    • Elevated cardiac troponin levels suggest the presence of myocardial cell injury or death.
    • Cardiac troponin levels may increase in patients with chronic or acute decompensated HF.[6]
  • Natriuretic Peptides:
    • Natriuretic peptides (BNP/NT-proBNP) are released from the heart in response to increased myocardial stress and are quantitative markers of increased intracardiac filling pressure.[7]
    • Elevated BNP and NT-proBNP are of both diagnostic and prognostic significance in patients with heart failure.
    • Increased BNP or NT-proBNP levels have been demonstrated in COVID-19 patients.
    • Increased NT-proBNP level was associated with worse clinical outcomes in patients with severe COVID-19.[8] [9]
    • However, increased natriuretic peptide levels are frequently seen among patients with severe inflammatory or respiratory diseases.[10] [11] [12] [13] [14]
    • Therefore, routine measurement of BNP/NT-proBNP has not been recommended in COVID-19 patients, unless there is a high suspicion of HF based on clinical grounds.

Electrocardiogram

X-ray

  • An x-ray may be helpful in the diagnosis of heart failure. Findings on an x-ray suggestive of heart failure include:
    • Cardiomegaly
    • Pulmonary congestion
    • Increased pulmonary vascular markings.
  • However, signs of pulmonary edema may be obscured by underlying respiratory involvement and ARDS due to COVID-19.

Echocardiography or Ultrasound

  • A complete standard transthoracicechocardiography (TTE) has not been recommended in COVID-19 patients considering the limited personal protective equipment (PPE) and the risk of exposure of additional health care personnel.[15]
  • To deal with limited resources (both personal protective equipment and personnel) and reducing the exposure time of personnel, a focused TTE to find gross abnormalities in cardiac structure/function seems satisfactory.
  • In addition, bedside options, which may be performed by the trained personnel who might already be in the room with these patients, might also be considered. These include:
  • Cardiac ultrasound can help in assessing the following parameters:
    • Left ventricular systolic function (ejection fraction) to distinguish systolic dysfunction with a reduced ejection fraction (<40%) from diastolic dysfunction with a preserved ejection fraction.
    • Left ventricular diastolic function
    • Left ventricular structural abnormalities, including LV size and LV wall thickness
    • Left atrial size
    • Right ventricular size and function
    • Detection and quantification of valvular abnormalities
    • Measurement of systolic pulmonary artery pressure
    • Detection and quantification of pericardial effusion
    • Detection of regional wall motion abnormalities/reduced strain that would suggest underlying ischemia.

CT scan

MRI

Other Imaging Findings

Other Diagnostic Studies

Treatment

Medical Therapy

References

  1. PMID 32219357 (PMID 32219357)
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  2. PMID 32360242 (PMID 32360242)
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  3. PMID 32186331 (PMID 32186331)
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  4. PMID 30625066 (PMID 30625066)
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  5. PMID 32140732 (PMID 32140732)
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  6. PMID 20863950 (PMID 20863950)
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  7. PMID 28062628 (PMID 28062628)
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  8. PMID 32293449 (PMID 32293449)
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  9. PMID 32232979 (PMID 32232979)
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  10. PMID 18298480 (PMID 18298480)
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  11. PMID 16442916 (PMID 16442916)
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  12. PMID 28322314 (PMID 28322314)
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  13. PMID 23837838 (PMID 23837838)
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  14. PMID 21478812 (PMID 21478812)
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  15. PMID 32391912 (PMID 32391912)
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  16. PMID 24251454 (PMID 24251454)
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  18. PMID 31129923 (PMID 31129923)
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