COVID-19-associated heart failure
WikiDoc Resources for COVID-19-associated heart failure
Evidence Based Medicine
Guidelines / Policies / Govt
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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. ; Associate Editor(s)-in-Chief: Mitra Chitsazan, M.D.Mandana Chitsazan, M.D. 
Synonyms and Keywords: Novel coronavirus, COVID-19, Wuhan coronavirus, coronavirus disease-19, coronavirus disease 2019, SARS-CoV-2, 2019-nCoV, 2019 novel coronavirus, heart failure, 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 a preserved ejection fraction
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 advanced age and the presence of multiple comorbidities.
- In late December 2019, the novel coronavirus, SARS-CoV-2, originated in Wuhan, China. 
- The World Health Organization(WHO) declared the outbreak a Public Health Emergency of International Concern On January 30, 2020,  and a pandemic on March 12, 2020. 
- On March 27, 2020, Inciardi et al. reported the first case of acute myopericarditis complicated by heart failure in an otherwise healthy 53-year-old woman one week after the onset of symptoms of COVID-19. 
- Heart Failure (HF) during COVID-19 infection may be classified similarly to heart failure from other causes.
- In general, heart failure can be classified based on:
- The pathophysiology of heart failure:
- The duration of symptoms:
- The underlying physiology based on left ventricular ejection fraction (LVEF):
- 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)
- Presumed pathophysiologic mechanisms for the development of new or decompensated heart failure in patients with COVID-19 include:    
- Acute exacerbation of chronic heart failure caused by precipitating factors
- Acute myocardial injury (which in turn can be caused by several mechanisms)
- Stress cardiomyopathy (i.e., Takotsubo cardiomyopathy)  
- 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)
|Common Precipitating factors in COVID-19 patients|
|Increased systemic metabolic demand|
- Acute myocardial injury
- Acute coronary syndromes
- Hypertensive crisis
- Arrhythmias: Tachycardia or severe bradycardia
- Stress-induced cardiomyopathy (Takotsubo cardiomyopathy)
- Circulatory failure:
Differentiating COVID-19 associated heart failure from other Diseases
- For further information about the differential diagnosis, click here.
Epidemiology and Demographics
- Data on incidence on acute heart failure in COVID-19 patients is limited.
- In one study, acute heart failure was seen in 4.1% of patients with acute cardiac injury. 
- In a retrospective study on 191 COVID-19 patients in Wuhan, China, the incidence of heart failure was 23% (52% in non-survivors vs 12% in survivors). 
- The most common risk factors in the development of acute heart failure in COVID-19 patients are:
- There is insufficient evidence to recommend routine screening for heart failure in COVID-19 patients.
- Routine measurement of natriuretic peptides and/or cardiac troponins has not been recommended in the absence of a high index of suspicion for heart failure 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 acute heart failure or acute decompensated heart failure) generally have worse outcomes.
- Acute heart failure in COVID-19 may progress to cardiogenic shock.
History and Symptoms
- The most common symptoms of acute heart failure in COVID-19 patients are:
- Other common symptoms include:
- Physical examination of patients with acute heart failure is usually remarkable for:
- Cardiac Troponins: 
- 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.
- 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.
- However, increased natriuretic peptide levels are frequently seen among patients with severe inflammatory or respiratory diseases.
- There is no specific electrocardiographic finding for acute heart failure in COVID-19 patients.
- The ECG may help in identifying preexisting cardiac abnormalities and precipitating factors, such as ischemia, myocarditis, and arrhythmias.
- These ECG findings may include:
- A Chest x-ray may be helpful in the diagnosis of heart failure. Findings on chest X-ray suggestive of heart failure include:
- However, signs of pulmonary edema may be obscured by underlying respiratory involvement and acute respiratory distress syndrome 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.
- 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 (left ventricular ejection fraction, LVEF) to distinguish systolic dysfunction with a reduced ejection fraction (LVEF<40%) from diastolic dysfunction with a preserved ejection fraction (LVEF>40%)
- Left ventricular diastolic function
- Left ventricular structural abnormalities, including left ventricular size and left ventricular 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.
- A Chest CT scan may be helpful in the diagnosis of pulmonary edema in patients with heart failure.
- Findings suggestive of pulmonary edema include:
- In patients with cardiogenic pulmonary edema, caused by increased pulmonary vasculature hydrostatic pressure, bilateral pleural effusions are also frequently seen.
- Due to the risk of contamination of equipment and staff, performing Cardiac magnetic resonance (CMR) should be limited to clinically urgent cases.
- Cardiac magnetic resonance may be helpful in patients suspicious of acute myocarditis, in particular when elevated cardiac biomarkers, ventricular dysfunction and/or severe arrhythmias cannot be explained by other diagnostics and imaging studies.
- To read more on the role of CMR in the diagnosis of myocarditis, 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.
- Acute heart failure in the setting of COVID-19 is generally treated similarly to acute heart failure in other settings. These may include:
- Beta-blockers should not be initiated during the acute stage due to their negative inotropic effects.
- Patients with chronic heart failure are recommended to continue their previous guideline-directed medical therapy, including beta-blockers, ACE inhibitors or Angiotensin II receptor blockers, and mineralocorticoid receptor antagonists. 
- Extracorporeal membrane oxygenation (ECMO) may be helpful in patients with cardiogenic shock unresponsive to medical therapy.
- The mainstay of treatment for acute heart failure is medical therapy.
- Ventricular assisted devices are usually reserved for patients with cardiogenic shock.
- There are no established measures for the primary prevention of heart failure in patients with COVID-19.
- During fluid management in heart failure patients, attempts would be done to prevent both volume overload and circulatory failure.
- Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) should be used with caution in patients with acute heart failure due to their effect on fluid and sodium retention.
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