COVID-19-associated cardiogenic shock
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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
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.
- 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. 
- On March 12, 2020, the WHO declared the Coronavirus disease 2019 (COVID-19) outbreak to be a pandemic.
- 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. 
To view the historical perspective of COVID-19, click here.
- There is no specific classification for COVID-19 associated cardiogenic shock. To view cardiogenic shock classification, click here.
- Direct invasion of the virus into the cardiomyocytes
- Cytokine storm activated by T helper cells (Th1 and Th2) that triggers a systemic hyperinflammatory response
- 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
Some hemodynamic parameters would help differentiate significant types of shock: 
|Cardiac Output||Pulmonary Capillary Wedge Pressure||Systemic Vascular Resistance||Pulmonary artery diastolic pressure||SVO2|
|COVID-19-associated cardiogenic 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. There are few anecdotal reports of cardiogenic shock related to COVID-19.  
- 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.
- 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.
- 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%. 
- In spite of using Extracorporeal membrane oxygenation (ECMO), 83% of patients who suffered of cardiogenic shock in covid-19 died.  
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,
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:  
- 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: 
- In addition, the increase of some biomarkers demonstrates poor prognosis, increased mortality, and more severe symptoms in COVID-19 patients:
- 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 
- 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. 
Echocardiography or Ultrasound
- Echocardiography is an appropriate way to identify the extent of cardiac involvement in COVID-19-associated cardiogenic shock cases.
- 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.
To view the CT scan findings on COVID-19, click here.
- Findings of cardiac MRI in the case series of young males with covid-19 and biventricular failure are: (doi:10.1161/CIRCHEARTFAILUREURE.120.007485)
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.
Cardiogenic shock medical therapy:
- 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.
- 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 
- 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.  
- Surgical intervention is not recommended for the management of COVID-19-associated cardiogenic shock.
- There are no established measures for the primary prevention of COVID-19-associated cardiogenic shock.
For secondary preventive measures of [COVID-19], click here.
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