COVID-19-associated cardiogenic shock

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For COVID-19 frequently asked inpatient questions, click here
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: : Alieh Behjat, M.D.[2]

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

The first confirmed instance of cardiogenic shock due to COVID-19 infection through myocardial infiltration by viral particles was in a 69-year-old patient from Italy. This was confirmed via biopsy. Since then, the two most probable mechanisms of cardiogenic shock related to COVID-19 are direct invasion and cytokine storm. According to a recent study out of an ICU in Washington state, one-third of critically ill patients with COVID-19 had clinical signs of cardiogenic shock and cardiomyopathy. According to another observational study in China, COVID-19 associated cardiogenic shock has a poor prognosis.

Historical Perspective


To view the historical perspective of COVID-19, click here.

Classification

Pathophysiology

The two most likely mechanisms that contribute to COVID-19 cardiogenic shock are: [5] [6]

Causes

The causes of cardiogenic shock related to COVID-19 may include: [7] [8]

Differentiating COVID-19 associated cardiogenic shock from other Diseases

Cardiogenic shock related to COVID-19 must be differentiated from other diseases which include: [9] [10]

Some hemodynamic parameters would help differentiate significant types of shock: [11]

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

Age

Gender

Race

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

Natural History, Complications and Prognosis

Diagnosis

Diagnostic Study of Choice


To view cardiogenic shock diagnostic criteria, click here.

History and Symptoms:

  • A 69-year-old patient from Italy has been reported by Tavazzi et al., as a COVID-19-associated cardiogenic shock case.

Physical Examination

Physical examination findings that may be of note for the diagnosis of Covid-19 associated cardiogenic shock include:[16]

Laboratory Findings

  • In addition, the increase of some biomarkers demonstrates poor prognosis, increased mortality, and more severe symptoms in COVID-19 patients:[18]

Electrocardiogram

X-ray

Echocardiography or Ultrasound

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.[20]


To view the CT scan findings on COVID-19, click here.

MRI


To view the MRI findings on COVID-19, click here.

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:

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. [22] [14]

Surgery

Primary Prevention

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

  1. https://www.cdc.gov/coronavirus/2019-ncov/about/index.html. Missing or empty |title= (help)
  2. 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.
  3. "Coronavirus (COVID-19) events as they happen".
  4. 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.
  5. 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.
  6. 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. 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.
  8. 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.
  9. 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.
  10. 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.
  11. Jameson, J (2018). Harrison's principles of internal medicine. New York: McGraw-Hill Education. ISBN 1259644030.
  12. 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).
  13. 13.0 13.1 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.
  14. 14.0 14.1 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).
  15. 15.0 15.1 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.
  16. Tse, FirstName (2011). Oxford Desk Reference : Cardiology. Oxford: OUP Oxford. ISBN 978-0-19-956809-3.
  17. 17.0 17.1 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.
  18. 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.
  19. Tse, FirstName (2011). Oxford Desk Reference : Cardiology. Oxford: OUP Oxford. ISBN 978-0-19-956809-3.
  20. 20.0 20.1 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.
  21. 21.0 21.1 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).
  22. 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.