COVID-19-associated heart failure

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief:

Synonyms and keywords:

Overview

  • Patients with chronic heart failure (HF) may be at higher risk of developing severe COVID-19 infection due to the advanced age and the presence of multiple comorbidities.
  • Both de novo acute heart failure and acute decompensation of chronic heart failure can occur in patients with COVID-19.

Classification

Pathophysiology

Presumed pathophysiologic mechanisms for the development of new or worsening heart failure in patients with COVID-19 include:[1] [2] [3] [4] [5]

    • Acute exacerbation of chronic heart failure
    • 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)

Causes

Disease name] may be caused by [cause1], [cause2], or [cause3].

OR

Common causes of [disease] include [cause1], [cause2], and [cause3].

OR

The most common cause of [disease name] is [cause 1]. Less common causes of [disease name] include [cause 2], [cause 3], and [cause 4].

OR

The cause of [disease name] has not been identified. To review risk factors for the development of [disease name], click here.

Differentiating ((Page name)) from other Diseases

[Disease name] must be differentiated from other diseases that cause [clinical feature 1], [clinical feature 2], and [clinical feature 3], such as [differential dx1], [differential dx2], and [differential dx3].

OR

[Disease name] must be differentiated from [[differential dx1], [differential dx2], and [differential dx3].

Epidemiology and Demographics

The incidence/prevalence of [disease name] is approximately [number range] per 100,000 individuals worldwide.

OR

In [year], the incidence/prevalence of [disease name] was estimated to be [number range] cases per 100,000 individuals worldwide.

OR

In [year], the incidence of [disease name] is approximately [number range] per 100,000 individuals with a case-fatality rate of [number range]%.


Patients of all age groups may develop [disease name].

OR

The incidence of [disease name] increases with age; the median age at diagnosis is [#] years.

OR

[Disease name] commonly affects individuals younger than/older than [number of years] years of age.

OR

[Chronic disease name] is usually first diagnosed among [age group].

OR

[Acute disease name] commonly affects [age group].


There is no racial predilection to [disease name].

OR

[Disease name] usually affects individuals of the [race 1] race. [Race 2] individuals are less likely to develop [disease name].


[Disease name] affects men and women equally.

OR

[Gender 1] are more commonly affected by [disease name] than [gender 2]. The [gender 1] to [gender 2] ratio is approximately [number > 1] to 1.


The majority of [disease name] cases are reported in [geographical region].

OR

[Disease name] is a common/rare disease that tends to affect [patient population 1] and [patient population 2].

Risk Factors

There are no established risk factors for [disease name].

OR

The most potent risk factor in the development of [disease name] is [risk factor 1]. Other risk factors include [risk factor 2], [risk factor 3], and [risk factor 4].

OR

Common risk factors in the development of [disease name] include [risk factor 1], [risk factor 2], [risk factor 3], and [risk factor 4].

OR

Common risk factors in the development of [disease name] may be occupational, environmental, genetic, and viral.

Screening

There is insufficient evidence to recommend routine screening for [disease/malignancy].

OR

According to the [guideline name], screening for [disease name] is not recommended.

OR

According to the [guideline name], screening for [disease name] by [test 1] is recommended every [duration] among patients with [condition 1], [condition 2], and [condition 3].

Natural History, Complications, and Prognosis

If left untreated, [#]% of patients with [disease name] may progress to develop [manifestation 1], [manifestation 2], and [manifestation 3].

OR

Common complications of [disease name] include [complication 1], [complication 2], and [complication 3].

OR

Prognosis is generally excellent/good/poor, and the 1/5/10-year mortality/survival rate of patients with [disease name] is approximately [#]%.

Diagnosis

Diagnostic Study of Choice

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], and [criterion 4].

OR

The diagnosis of [disease name] is based on the [criteria name] criteria, which include [criterion 1], [criterion 2], and [criterion 3].

OR

The diagnosis of [disease name] is based on the [definition name] definition, which includes [criterion 1], [criterion 2], and [criterion 3].

OR

There are no established criteria for the diagnosis of [disease name].

History and Symptoms

The majority of patients with [disease name] are asymptomatic.

OR

The hallmark of [disease name] is [finding]. A positive history of [finding 1] and [finding 2] is suggestive of [disease name]. The most common symptoms of [disease name] include [symptom 1], [symptom 2], and [symptom 3]. Common symptoms of [disease] include [symptom 1], [symptom 2], and [symptom 3]. Less common symptoms of [disease name] include [symptom 1], [symptom 2], and [symptom 3].

Physical Examination

Patients with [disease name] usually appear [general appearance]. Physical examination of patients with [disease name] is usually remarkable for [finding 1], [finding 2], and [finding 3].

OR

Common physical examination findings of [disease name] include [finding 1], [finding 2], and [finding 3].

OR

The presence of [finding(s)] on physical examination is diagnostic of [disease name].

OR

The presence of [finding(s)] on physical examination is highly suggestive of [disease name].

Laboratory Findings

  • Cardiac Troponins:
    • Elevated cardiac troponin levels suggest the presence of myocardial cell injury or death.
    • Cardiac troponin levels may increase in patients with chronic or acute decompensated HF.[6]
  • 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.[7]
    • 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.[8] [9]
    • However, increased natriuretic peptide levels are frequently seen among patients with severe inflammatory or respiratory diseases.[10] [11] [12] [13] [14]
    • Therefore, routine measurement of BNP/NT-proBNP has not been recommended in COVID-19 patients, unless there is a high suspicion of HF based on clinical grounds.

Electrocardiogram

  • 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:
    • Low QRS Voltage
    • Left ventricular hypertrophy
    • Left atrial enlargement
    • Left bundle branch block
    • Poor R progression
    • ST-T changes

X-ray

An x-ray may be helpful in the diagnosis of heart failure. Findings on an x-ray suggestive of heart failure include:

    • Cardiomegaly
    • Pulmonary congestion
    • Increased pulmonary vascular markings.
  • However, signs of pulmonary edema may be obscured by underlying respiratory involvement and ARDS due to COVID-19.

Echocardiography or Ultrasound

  • A complete standard transthoracic (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.[15]
  • 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 point-of-care ultrasound (POCUS)
    • Focused cardiac ultrasound study (FoCUS)
    • Critical care echocardiography
  • Cardiac ultrasound can help in assessing the following parameters:
    • Left ventricular systolic function (ejection fraction) to distinguish systolic dysfunction with a reduced ejection fraction (<40%) from diastolic dysfunction with a preserved ejection fraction.
    • Left ventricular diastolic function
    • Left ventricular structural abnormalities, including LV size and LV 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.

CT scan

There are no CT scan findings associated with [disease name].

OR

[Location] CT scan may be helpful in the diagnosis of [disease name]. Findings on CT scan suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].

OR

There are no CT scan findings associated with [disease name]. However, a CT scan may be helpful in the diagnosis of complications of [disease name], which include [complication 1], [complication 2], and [complication 3].

MRI

There are no MRI findings associated with [disease name].

OR

[Location] MRI may be helpful in the diagnosis of [disease name]. Findings on MRI suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].

OR

There are no MRI findings associated with [disease name]. However, a MRI may be helpful in the diagnosis of complications of [disease name], which include [complication 1], [complication 2], and [complication 3].

Other Imaging Findings

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

OR

[Imaging modality] may be helpful in the diagnosis of [disease name]. Findings on an [imaging modality] suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].

Other Diagnostic Studies

There are no other diagnostic studies associated with [disease name].

OR

[Diagnostic study] may be helpful in the diagnosis of [disease name]. Findings suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].

OR

Other diagnostic studies for [disease name] include [diagnostic study 1], which demonstrates [finding 1], [finding 2], and [finding 3], and [diagnostic study 2], which demonstrates [finding 1], [finding 2], and [finding 3].

Treatment

Medical Therapy

  • Acute heart failure in the setting of COVID-19 is generally treated similarly to acute heart failure in other settings. These may include:
    • Fluid restriction
    • Diuretic therapy
    • Vasopressors and/or inotropes
    • Ventricular assisted devices and extracorporeal membrane oxygenation (ECMO)
  • Beta-blockers should not be initiated during the acute stage due to their negative inotropic effects.[16]
  • 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.[17]
  • Patients with chronic heart failure are recommended to continue their previous guideline-directed medical therapy, including beta-blockers, ACEI or ARB, and mineralocorticoid receptor antagonists. [18]

References

  1. PMID 32219357 (PMID 32219357)
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  2. PMID 32360242 (PMID 32360242)
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  3. PMID 32186331 (PMID 32186331)
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  4. PMID 30625066 (PMID 30625066)
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  5. PMID 32140732 (PMID 32140732)
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  6. PMID 20863950 (PMID 20863950)
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  7. PMID 28062628 (PMID 28062628)
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  8. PMID 32293449 (PMID 32293449)
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  9. PMID 32232979 (PMID 32232979)
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  10. PMID 18298480 (PMID 18298480)
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  11. PMID 16442916 (PMID 16442916)
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  12. PMID 28322314 (PMID 28322314)
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  13. PMID 23837838 (PMID 23837838)
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  14. PMID 21478812 (PMID 21478812)
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  15. PMID 32391912 (PMID 32391912)
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  16. PMID 24251454 (PMID 24251454)
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  17. PMID 12656651 (PMID 12656651)
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  18. PMID 31129923 (PMID 31129923)
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