COVID-19-associated cardiogenic shock
For COVID-19 frequently asked inpatient questions, click here
For COVID-19 frequently asked outpatient questions, click here
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: : Sara Zand, M.D.[2] Alieh Behjat, M.D.[3]
Synonyms and keywords:: Novel coronavirus, COVID-19, Wuhan coronavirus, coronavirus disease-19, coronavirus disease 2019, SARS-CoV-2, COVID-19, 2019-nCoV, 2019 novel coronavirus, cardiovascular finding in COVID-19, cardiogenic shock, COVID-19 associated cardiogenic shock
Overview
SARS-COV-2 or COVID-19 is a specific strain of coronavirus that is responsible for an ongoing global pandemic. COVID-19 may lead to respiratory disease and also multi-organ dysfunction including biventricular failure and profound shock and life threatening cardiogenic shock. Cardiogenic shock shoulb be considered while cardiac ethiology is evident in patients with persistent hypotesion despite fluide resuscitation in the presence of end organs dysfunction. Cardiogenic shock may present as a consequence of cytokine storm pathway or direct invasion of cardiovascular system by virus via ACE2 receptos on the cells. Cardiogenic shock may progress to develop quicky in covid-19 patients and any delay for diagnosis and treatment of such patients will increase mortality rate. In mild or severe types of covid-19 with sudden collapse of hemodynamic, considering different causes of cardiogenic shock including fulminant myocarditis, acute STEMI, massive pulmonary thromboembolism, stress cardiomyopathy, are helpful to clinical approach and quickly initiation of treatment. Mortality rate of covid-19 patients with cardiogenic shock among reported cases in literature was 75% despite use of pharmacological and mechanichal hemodynamic support.
Historical Perspective
- The novel coronavirus, SARS-CoV-2, is identified as the cause of an outbreak of respiratory illness first detected in Wuhan, China in late December 2019. It was named SARS-CoV-2 for its similarity severe acute respiratory syndrome related coronaviruses such as SARS-CoV, which caused acute respiratory distress syndrome (ARDS) in 2002–2003. [1][2]
- On March 12, 2020, the WHO declared the Coronavirus disease 2019 (COVID-19) outbreak to be a pandemic.[3]
- The first confirmed instance of cardiogenic shock due to COVID-19 infection through myocardial infection by viral particles was in a 69-year-old patient from Italy. This was confirmed via biopsy. [4]
To view the historical perspective of COVID-19, click here.
Classification
- There is no specific classification for COVID-19 associated cardiogenic shock. To view cardiogenic shock classification, click here.
Pathophysiology
The two most likely mechanisms that contribute to COVID-19 cardiogenic shock are: [5] [6]
- Direct invasion of the virus into the cardiomyocytes
- Cytokine storm activated by T helper cells (Th1 and Th2) that triggers a systemic hyperinflammatory response
Causes
Common causes of cardiogenic shock in patients with covid-19 include:[7][8] [9]
- Acute myocarditis
- Acute coronary syndrome
- Stress cardiomyopathy
- Pulmonary thromboembolism
- Worsening of previous left ventricular failure due to COVID-19
- COVID-19-associated multisystem inflammatory syndromein children (MIS-C)
Differentiating COVID-19 associated cardiogenic shock from other Diseases
Cardiogenic shock related to COVID-19 must be differentiated from other diseases which include: [10] [11]
- Distributive shock
- Hypovolemic shock
- Mixed (distributive and cardiogenic shock).
Some hemodynamic parameters would help differentiate significant types of shock: [12]
Cardiac Output | Pulmonary Capillary Wedge Pressure | Systemic Vascular Resistance | Pulmonary artery diastolic pressure | SVO2 | |
---|---|---|---|---|---|
COVID-19-associated cardiogenic shock | ↓ | ↑↔ | ↑ | ↑ | ↓ |
Septic shock | ↑ | ↓ | ↓ | ↓ | ↓ |
Hypovolemic shock | ↓ | ↓ | ↑ | ↓ | ↑ |
Epidemiology and Demographics
- According to a recent study of an ICU in Washington state, one-third of critically ill patients with COVID-19 had clinical signs of cardiogenic shock and cardiomyopathy.[13] There are few anecdotal reports of cardiogenic shock related to COVID-19. [4] [14]
Age
- There is no data on age predilection to cardiogenic shock in COVID-19.
Gender
- There is no data on gender predilection to cardiogenic shock in COVID-19.
Race
- There is no data on racial predilection to cardiogenic shock in COVID-19.
Risk Factors
- There are no established risk factors for COVID-19-associated cardiogenic shock.
- To view risk factors for the severe form of COVID-19 disease, click here.
- Moreover, in order to read more on the risk factors of cardiogenic shock, generally, click here.
Screening
- There is insufficient evidence to recommend routine screening for COVID-19-associated cardiogenic shock.
Natural History, Complications and Prognosis
- Cardiogenic shock can develop suddenly in covid-19 patients without underlying risk factors of cardiovascular disease.[15]
- If left untreated, patients with cardiogenic shock may progress to develope hemodynamic collapse, death.
- Prognosis is generally poor, and mortality rate of cardiogenic shock in covid-19 reported cases was approximately 75%. [7]
- In spite of using Extracorporeal membrane oxygenation (ECMO), 83% of patients who suffered of cardiogenic shock in covid-19 died. [16] [17]
Diagnosis
Diagnostic Study of Choice
- A diagnosis of cardiogenic shock related to COVID-19 can be made when systolic Blood Pressure is lower than 90 mmHg for more than 30 minutes,
cardiac index ≤ 2.2L/min per m². pulmonary capillary wedge pressure ≥ 15 mmHg with impaired organ perfusion including:
- Urine output is less than 30 m/hr
- Cool extermities
- Altered mental status
- Serum lactate> 2 mmol/L
- Use of pharmacological or mechanical support to maintain an BP ≥ 90mmHg[17]
History and Symptoms:
- Cardiogenic shock should be considered in covid-19 patients who present with suddenly hypotension, cool extremities, reslesness, shortness of breath, chest discomfort, palpitation.
- Cardiac biomarkers sampling, cardiac monitoring , obtaining ECG, evaluation of cardiac function by echocardiography are considered.
- In the presence of tachyarrhythmia or bradyarrhythmia and evidence of hypotension and pulmonary edema, evaluation about fulminant myocarditis, acute STEMI are warranted.
- In the presence of unilateral or bilateral lower limbs edema and suddenly refractory hypotension , tachycardia, and tachypnea, massive pulmonary thromboembolism should be considered.
- Table bellow shown the clinical characteristics of patients with covid-19 associated with cardiogenic shock:[7][15] [4] [14]
Physical Examination
- Physical examination in covid-19 associated cardiogenic shock include:
- Assessment of consciousness level
- Extremities, warm or cool
- Vital signs (tachycardia and hypotension and tachypnea)
- Evaluation of volume status: CVP (increased JVP), lower limbs edema)
- Skin pallor
- Ascultation of Rale in lung fields and cardiac murmurs
Laboratory Findings
- In COVID-19 patients, it is essential to differentiate the type of shock. Two tests are best able to clarify this, and result in higher levels in patients with cardiogenic shock related to COVID-19. These tests are: [18]
- serum brain natriuretic peptide (BNP)
- Troponin
- In addition, the increase of some biomarkers demonstrates poor prognosis, increased mortality, and more severe symptoms in COVID-19 patients:[19]
Electrocardiogram
- There is no specific electrocardiographic finding for cardiogenic shock in COVID-19 patients.
- The ECG can be helpful to find previous cardiac abnormalities and triggering factors, such as acute myocardial infarction, and arrhythmias, which could lead to cardiogenic shock [20]
X-ray
- In a patient with COVID-19-associated cardiogenic shock, CXR could manifest coexisting acute respiratory illness and also cardiogenic pulmonary edema. Some findings, such as cardiomegaly and increased vascular markings, can suggest preexisting heart failure. [21]
Echocardiography or Ultrasound
- Echocardiography is an appropriate way to identify the extent of cardiac involvement in COVID-19-associated cardiogenic shock cases.[18]
CT scan
- Generally, aCT scan is not suggested as a primary imaging study for evaluating a case of cardiogenic shock related to COVID-19. However, it can useful for observing coexisting ARDS by demonstrating a ground-glass opacity.[21]
To view the CT scan findings on COVID-19, click here.
MRI
- Findings of cardiac MRI in the case series of young males with covid-19 and biventricular failure are: (doi:10.1161/CIRCHEARTFAILUREURE.120.007485)
- Mild nonspecific late gadolinium enhancement in some cases
- NO evidence of myocardial edema on T2 weighted imaging
Other Imaging Findings
- To view other imaging findings on COVID-19, click here.
Other Diagnostic Studies
- To view other diagnostic studies for COVID-19, click here.
Treatment
Cardiogenic shock medical therapy:
The maistay of therapy of cardiogenic shock in covid-19 patients is respiratory and circulatory support.[7]
- In patients with myocarditis, administration of corticosteroids and immunoglobulins are recommended.
- Cardiogenic shock in the setting of stress cardiomyopathy can be triggered by catecholamine discharge secondary to hypoxia or sepsis and should be managed by mechanical support.
- Treatment of cardiogenic shock due to pulmonary thromboembolism include implantation of VA ECMO, thrombolysis, percutaneous treatment in case of thrombolysis contraindicated or failed.
- In the presence of cardiogenic shock due to acute coronary thrombosis , revascularization by PCI or CABG based on the arterial anatomical involvement are warranted.
- In the case series of young males with covid-19 and cardiogenic shock and biventricular failure with high level of hyperinflammatory biomarkers, use of moderate-dose steroid, anticoagulant, supportive care led to recovery of shock quickly.[22]
- General approach for patients with shock is:
- Fluid resuscitation (crystalloid IV fluids are more efficient than colloid solutions)
- Administration of vasopressors and inotropes to stabilize shock
- Mixed etiologies of shock should be considered in covid-19 infection if hemodynamics not refining, specifically in patients with a previous cardiac abnormality [23]
Mechanical Support:
- In treating patients with cardiogenic shock related to COVID-19, the efficacy of extracorporeal membrane oxygenation (ECMO) is indistinct, however it may be used in the most critically ill and highly selective patients.
- Although specialists implicate ECMO and mechanical circulatory support devices in severe cased of COVID-19 related cardiogenic shock, the mortality rate if high in those patients who undergo this treatment.
- It has been reported in a case series from China, that most of these patients had a poor prognosis and did not survive despite implicating ECMO. [24] [16]
Surgery
- Surgical intervention is not recommended for the management of COVID-19-associated cardiogenic shock.
Primary Prevention
- There are no established measures for the primary prevention of COVID-19-associated cardiogenic shock.
For primary preventive measures of COVID-19, click here.
Secondary Prevention
- There are no established measures for the secondary prevention of COVID-19-associated myocarditis.
For secondary preventive measures of [COVID-19], click here.
References
- ↑ https://www.cdc.gov/coronavirus/2019-ncov/about/index.html. Missing or empty
|title=
(help) - ↑ Lu, Jian; Cui, Jie; Qian, Zhaohui; Wang, Yirong; Zhang, Hong; Duan, Yuange; Wu, Xinkai; Yao, Xinmin; Song, Yuhe; Li, Xiang; Wu, Changcheng; Tang, Xiaolu (2020). "On the origin and continuing evolution of SARS-CoV-2". National Science Review. doi:10.1093/nsr/nwaa036. ISSN 2095-5138.
- ↑ 4.0 4.1 4.2 Tavazzi, Guido; Pellegrini, Carlo; Maurelli, Marco; Belliato, Mirko; Sciutti, Fabio; Bottazzi, Andrea; Sepe, Paola Alessandra; Resasco, Tullia; Camporotondo, Rita; Bruno, Raffaele; Baldanti, Fausto; Paolucci, Stefania; Pelenghi, Stefano; Iotti, Giorgio Antonio; Mojoli, Francesco; Arbustini, Eloisa (2020). "Myocardial localization of coronavirus in COVID‐19 cardiogenic shock". European Journal of Heart Failure. 22 (5): 911–915. doi:10.1002/ejhf.1828. ISSN 1388-9842.
- ↑ Siddiqi, Hasan K.; Mehra, Mandeep R. (2020). "COVID-19 illness in native and immunosuppressed states: A clinical–therapeutic staging proposal". The Journal of Heart and Lung Transplantation. 39 (5): 405–407. doi:10.1016/j.healun.2020.03.012. ISSN 1053-2498.
- ↑ Ye, Qing; Wang, Bili; Mao, Jianhua (2020). "The pathogenesis and treatment of the `Cytokine Storm' in COVID-19". Journal of Infection. 80 (6): 607–613. doi:10.1016/j.jinf.2020.03.037. ISSN 0163-4453.
- ↑ 7.0 7.1 7.2 7.3 Sánchez-Recalde Á, Solano-López J, Miguelena-Hycka J, Martín-Pinacho JJ, Sanmartín M, Zamorano JL (August 2020). "COVID-19 and cardiogenic shock. Different cardiovascular presentations with high mortality". Rev Esp Cardiol (Engl Ed). 73 (8): 669–672. doi:10.1016/j.rec.2020.04.012. PMC 7184000 Check
|pmc=
value (help). PMID 32499016 Check|pmid=
value (help). - ↑ Mahajan, Kunal; Chandra, K.Sarat (2020). "Cardiovascular comorbidities and complications associated with coronavirus disease 2019". Medical Journal Armed Forces India. doi:10.1016/j.mjafi.2020.05.004. ISSN 0377-1237.
- ↑ Belhadjer, Zahra; Méot, Mathilde; Bajolle, Fanny; Khraiche, Diala; Legendre, Antoine; Abakka, Samya; Auriau, Johanne; Grimaud, Marion; Oualha, Mehdi; Beghetti, Maurice; Wacker, Julie; Ovaert, Caroline; Hascoet, Sebastien; Selegny, Maëlle; Malekzadeh-Milani, Sophie; Maltret, Alice; Bosser, Gilles; Giroux, Nathan; Bonnemains, Laurent; Bordet, Jeanne; Di Filippo, Sylvie; Mauran, Pierre; Falcon-Eicher, Sylvie; Thambo, Jean-Benoît; Lefort, Bruno; Moceri, Pamela; Houyel, Lucile; Renolleau, Sylvain; Bonnet, Damien (2020). "Acute heart failure in multisystem inflammatory syndrome in children (MIS-C) in the context of global SARS-CoV-2 pandemic". Circulation. doi:10.1161/CIRCULATIONAHA.120.048360. ISSN 0009-7322.
- ↑ Boukhris, Marouane; Hillani, Ali; Moroni, Francesco; Annabi, Mohamed Salah; Addad, Faouzi; Ribeiro, Marcelo Harada; Mansour, Samer; Zhao, Xiaohui; Ybarra, Luiz Fernando; Abbate, Antonio; Vilca, Luz Maria; Azzalini, Lorenzo (2020). "Cardiovascular Implications of the COVID-19 Pandemic: A Global Perspective". Canadian Journal of Cardiology. doi:10.1016/j.cjca.2020.05.018. ISSN 0828-282X.
- ↑ Rajagopal, Keshava; Keller, Steven P.; Akkanti, Bindu; Bime, Christian; Loyalka, Pranav; Cheema, Faisal H.; Zwischenberger, Joseph B.; El Banayosy, Aly; Pappalardo, Federico; Slaughter, Mark S.; Slepian, Marvin J. (2020). "Advanced Pulmonary and Cardiac Support of COVID-19 Patients". Circulation: Heart Failure. 13 (5). doi:10.1161/CIRCHEARTFAILURE.120.007175. ISSN 1941-3289.
- ↑ Jameson, J (2018). Harrison's principles of internal medicine. New York: McGraw-Hill Education. ISBN 1259644030.
- ↑ Arentz M, Yim E, Klaff L, Lokhandwala S, Riedo FX, Chong M; et al. (2020). "Characteristics and Outcomes of 21 Critically Ill Patients With COVID-19 in Washington State". JAMA. doi:10.1001/jama.2020.4326. PMC 7082763 Check
|pmc=
value (help). PMID 32191259 Check|pmid=
value (help). - ↑ 14.0 14.1 Sánchez-Recalde, Ángel; Solano-López, Jorge; Miguelena-Hycka, Javier; Martín-Pinacho, Jesús Javier; Sanmartín, Marcelo; Zamorano, José L. (2020). "COVID-19 and cardiogenic shock. Different cardiovascular presentations with high mortality". Revista Española de Cardiología (English Edition). doi:10.1016/j.rec.2020.04.012. ISSN 1885-5857.
- ↑ 15.0 15.1 Purdy A, Ido F, Sterner S, Tesoriero E, Matthews T, Singh A (February 2021). "Myocarditis in COVID-19 presenting with cardiogenic shock: a case series". Eur Heart J Case Rep. 5 (2): ytab028. doi:10.1093/ehjcr/ytab028. PMC 7953948 Check
|pmc=
value (help). PMID 33733043 Check|pmid=
value (help). - ↑ 16.0 16.1 Yang X, Yu Y, Xu J, Shu H, Xia J, Liu H; et al. (2020). "Clinical course and outcomes of critically ill patients with SARS-CoV-2 pneumonia in Wuhan, China: a single-centered, retrospective, observational study". Lancet Respir Med. 8 (5): 475–481. doi:10.1016/S2213-2600(20)30079-5. PMC 7102538 Check
|pmc=
value (help). PMID 32105632 Check|pmid=
value (help). - ↑ 17.0 17.1 Dhakal, Bishnu P.; Sweitzer, Nancy K.; Indik, Julia H.; Acharya, Deepak; William, Preethi (2020). "SARS-CoV-2 Infection and Cardiovascular Disease: COVID-19 Heart". Heart, Lung and Circulation. doi:10.1016/j.hlc.2020.05.101. ISSN 1443-9506.
- ↑ 18.0 18.1 Lal, Sean; Hayward, Christopher S.; De Pasquale, Carmine; Kaye, David; Javorsky, George; Bergin, Peter; Atherton, John J.; Ilton, Marcus K.; Weintraub, Robert G.; Nair, Priya; Rudas, Mate; Dembo, Lawrence; Doughty, Robert N.; Kumarasinghe, Gayathri; Juergens, Craig; Bannon, Paul G.; Bart, Nicole K.; Chow, Clara K.; Lattimore, Jo-Dee; Kritharides, Leonard; Totaro, Richard; Macdonald, Peter S. (2020). "COVID-19 and Acute Heart Failure: Screening the Critically Ill – A Position Statement of the Cardiac Society of Australia and New Zealand (CSANZ)". Heart, Lung and Circulation. doi:10.1016/j.hlc.2020.04.005. ISSN 1443-9506.
- ↑ Aboughdir, Maryam; Kirwin, Thomas; Abdul Khader, Ashiq; Wang, Brian (2020). "Prognostic Value of Cardiovascular Biomarkers in COVID-19: A Review". Viruses. 12 (5): 527. doi:10.3390/v12050527. ISSN 1999-4915.
- ↑ Tse, FirstName (2011). Oxford Desk Reference : Cardiology. Oxford: OUP Oxford. ISBN 978-0-19-956809-3.
- ↑ 21.0 21.1 Driggin, Elissa; Madhavan, Mahesh V.; Bikdeli, Behnood; Chuich, Taylor; Laracy, Justin; Biondi-Zoccai, Giuseppe; Brown, Tyler S.; Der Nigoghossian, Caroline; Zidar, David A.; Haythe, Jennifer; Brodie, Daniel; Beckman, Joshua A.; Kirtane, Ajay J.; Stone, Gregg W.; Krumholz, Harlan M.; Parikh, Sahil A. (2020). "Cardiovascular Considerations for Patients, Health Care Workers, and Health Systems During the COVID-19 Pandemic". Journal of the American College of Cardiology. 75 (18): 2352–2371. doi:10.1016/j.jacc.2020.03.031. ISSN 0735-1097.
- ↑ Chau VQ, Giustino G, Mahmood K, Oliveros E, Neibart E, Oloomi M, Moss N, Mitter SS, Contreras JP, Croft L, Serrao G, Parikh AG, Lala A, Trivieri MG, LaRocca G, Anyanwu A, Pinney SP, Mancini DM (October 2020). "Cardiogenic Shock and Hyperinflammatory Syndrome in Young Males With COVID-19". Circ Heart Fail. 13 (10): e007485. doi:10.1161/CIRCHEARTFAILURE.120.007485. PMID 32844662 Check
|pmid=
value (help). - ↑ Dhakal BP, Sweitzer NK, Indik JH, Acharya D, William P (2020). "SARS-CoV-2 Infection and Cardiovascular Disease: COVID-19 Heart". Heart Lung Circ. doi:10.1016/j.hlc.2020.05.101. PMC 7274628 Check
|pmc=
value (help). PMID 32601020 Check|pmid=
value (help). - ↑ MacLaren, Graeme; Fisher, Dale; Brodie, Daniel (2020). "Preparing for the Most Critically Ill Patients With COVID-19". JAMA. 323 (13): 1245. doi:10.1001/jama.2020.2342. ISSN 0098-7484.