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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Historical Perspective

• In Italy, for the first time in a 69-year-old patient, who was presented with cardiogenic shock due to COVID-19 infection, myocardial involvement by viral particles was pathologically proved through biopsy.

Classification

There is no specific classification for COVID-19 associated cardiogenic shock. For more information regarding general classification, see the cardiogenic shock classification.

Pathophysiology

Two mechanisms are more probable to contribute to cardiogenic shock related to Covid-19:

• Direct invasion of the virus into the cardiomyocytes
• Cytokine storm activated by T helper cells (Th1 and Th2) and trigger a systemic hyperinflammatory response.

Differentiating COVID-19 associated cardiogenic shock from other Diseases

• Cardiogenic shock related to COVID-19 must be differentiated from other diseases when hemodynamics not changing, such as:

• COVID-19 associated distributive shock
• COVID-19 associated hypovolemic shock
• COVID-19 associated mixed (distributive and cardiogenic shock)

Epidemiology and Demographics

• The prevalence of cardiogenic shock-associated COVID-19 has not yet been reported.There are several anecdotal reports of cardiogenic shock related to COVID-19:
• A 69-year-old patient from Italy has been reported by Tavazzi et al., as a cardiogenic shock-associated COVID-19 case. The patient had flu-like symptoms when he was hospitalized and quickly deteriorated into respiratory distress and cardiogenic shock.
• Four patients with cardiogenic shock complication related to COVID-19 were reported by Sanchez-Recalde, et al. They were hospitalized between 1 March and 15 April 2020 including:
  • A 42-year-old woman, who had dyslipidemia as a cardiovascular risk factor
  • A 50-year-old man, without any cardiovascular risk factors, admitted by severe bilateral pneumonia related to COVID-19. After a few hours, he developed cardiogenic shock.
  • A 75-year-old man did not have any cardiovascular risk factors and was admitted due to dyspnea, chest pain, and bilateral SARS-CoV-2 pneumonia.
  • A 37-year-old woman, obese with a history of deep venous thrombosis, had symptoms of dyspnea and chest pain

Causes

The causes of cardiogenic shock related to COVID-19 might include:

• Newly emerging COVID-19 associated myocarditis, cardiac arrhythmias, cardiomyopathy, or an acute coronary syndrome deteriorated into cardiogenic shock
• Worsening of previous left ventricular failure due to COVID-19

Complications and Prognosis

According to an observational study in China, COVID-19 associated cardiogenic shock has a poor prognosis. In spite of using Extracorporeal membrane oxygenation (ECMO), 83% of patients died.

Diagnosis

Diagnostic Criteria

• The diagnosis of [disease name] is made when at least [number] of the following [number] diagnostic criteria are met:

• [criterion 1]
• [criterion 2]
• [criterion 3]
• [criterion 4]

Symptoms

• [Disease name] is usually asymptomatic.
• Symptoms of [disease name] may include the following:

• [symptom 1]
• [symptom 2]
• [symptom 3]
• [symptom 4]
• [symptom 5]
• [symptom 6]

Physical Examination

• Patients with [disease name] usually appear [general appearance].
• Physical examination may be remarkable for:

• [finding 1]
• [finding 2]
• [finding 3]
• [finding 4]
• [finding 5]
• [finding 6]

Laboratory Findings

• There are no specific laboratory findings associated with [disease name].

• A [positive/negative] [test name] is diagnostic of [disease name].
• An [elevated/reduced] concentration of [serum/blood/urinary/CSF/other] [lab test] is diagnostic of [disease name].
• Other laboratory findings consistent with the diagnosis of [disease name] include [abnormal test 1], [abnormal test 2], and [abnormal test 3].

Imaging Findings

• There are no [imaging study] findings associated with [disease name].

• [Imaging study 1] is the imaging modality of choice for [disease name].
• On [imaging study 1], [disease name] is characterized by [finding 1], [finding 2], and [finding 3].
• [Imaging study 2] may demonstrate [finding 1], [finding 2], and [finding 3].

Other Diagnostic Studies

• [Disease name] may also be diagnosed using [diagnostic study name].
• Findings on [diagnostic study name] include [finding 1], [finding 2], and [finding 3].

Treatment

Medical Therapy

• There is no treatment for [disease name]; the mainstay of therapy is supportive care.

• The mainstay of therapy for [disease name] is [medical therapy 1] and [medical therapy 2].
• [Medical therapy 1] acts by [mechanism of action 1].
• Response to [medical therapy 1] can be monitored with [test/physical finding/imaging] every [frequency/duration].

Surgery

• Surgery is the mainstay of therapy for [disease name].
• [Surgical procedure] in conjunction with [chemotherapy/radiation] is the most common approach to the treatment of [disease name].
• [Surgical procedure] can only be performed for patients with [disease stage] [disease name].

Prevention

• There are no primary preventive measures available for [disease name].

• Effective measures for the primary prevention of [disease name] include [measure1], [measure2], and [measure3].

• Once diagnosed and successfully treated, patients with [disease name] are followed-up every [duration]. Follow-up testing includes [test 1], [test 2], and [test 3].