Sandbox:Sara Haddadi

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  1. Sara Haddadi MD, Miami FL

[1]

Natural History, Complications and Prognosis

In a case series with 187 patients who had confirmed COVID-19, 27.8% of patients had a myocardial injury, which caused cardiac dysfunction and arrhythmias. The result was significantly higher mortality among patients with myocardial injury.

  • Based on the Troponin level The mortality during hospitalization was shown to be as below:
    • 7.62% for patients without underlying CVD and normal TnT levels
    • 13.33% for those with underlying CVD and normal TnT levels
    • 37.50% for those without underlying CVD but elevated TnT levels
    • 69.44% for those with underlying CVD and elevated TnTs.[2]


Classification of Infra-Hisian Block
Types of Infra-Hisian Block Sub-type
Type 2 second degree heart block (Mobitz II) _
Left bundle branch block Left anterior fascicular block
Right bundle branch block _


Covid19. [1]


underlying medical conditions that increase a person’s risk of severe illness from COVID-19
Level of Evidence Condition
Strongest and Most Consistent Evidence
  • Serious heart conditions, such as heart failure, coronary artery disease, or cardiomyopathies
  • Cancer
  • Chronic kidney disease
  • COPD
  • Obesity (BMI> 30)
  • Sickle cell disease
  • Solid organ transplantation
Mixed Evidence Left anterior fascicular block
Limited Evidence _


References

  1. ↑ Thygesen K, Alpert JS, Jaffe AS, Chaitman BR, Bax JJ, Morrow DA; et al. (2018). "Fourth Universal Definition of Myocardial Infarction (2018)". J Am Coll Cardiol. 72 (18): 2231–2264. doi:10.1016/j.jacc.2018.08.1038. PMID 30153967.
  2. ↑ Guo T, Fan Y, Chen M, Wu X, Zhang L, He T; et al. (2020). "Cardiovascular Implications of Fatal Outcomes of Patients With Coronavirus Disease 2019 (COVID-19)". JAMA Cardiol. doi:10.1001/jamacardio.2020.1017. PMC 7101506 Check |pmc= value (help). PMID 32219356 Check |pmid= value (help).

6/20/2020

Acute Coronary Syndromes

Pathophysiology

The mechanism of COVID-19 cardiovascular injury has not been fully understood and is likely multifactorial.

  • SARS-CoV-2 virus attaches to ACE 2 protein for ligand binding before entering the cell via receptor-mediated endocytosis.
    • Based on single-cell RNA sequencing more than 7.5% of myocardial cells have positive ACE2 expression. This protein can mediate the entry of SARS-CoV-2 and result in direct cardiotoxicity.
  • The cytokine release caused by the virus may lead to vascular inflammation, plaque instability, myocardial inflammation, a hypercoagulable state, or direct myocardial suppression.

Pathological changes:

  • In the level of cardiac tissue: minimal change to interstitial inflammatory infiltration and myocyte necrosis
  • In the level of vasculature: micro-thrombosis and vascular inflammation[1]

ST-Elevation MI (STEMI)

A US model from 9 major centers showed a 38% drop in total STEMI activations during the COVID-19 pandemic. There is a 40% reduction noted in Spain as well. there was also a delay between the first presentation to a medical encounter up to 318 min. This is important since COVID-19 can potentially be a cause of STEMI through microthrombi, cytokine storm, coronary spasm, or direct endothelial injury.[2]

  • Potential etiologies for the reduction in STEMI PPCI activations:
    • avoidance of medical care due to social distancing or concerns of contracting COVID-19 in the hospital
    • STEMI misdiagnosis
    • increased use of pharmacological reperfusion due to COVID-19

It is very important to realize if patients' anxiety is the reason behind decreasing the presentation of STEMI to U.S. hospitals.[3]

  • Treatment of STEMI & COVID-19: The specific protocols for the treatment have been evolving. Early recommendations showed intravenous thrombolysis as first-line therapy for STEMI patients with confirmed COVID-19 since most hospitals do not have protected cardiac catheterization labs.[2]

Signs and Symptoms

The signs and symptoms of acute coronary syndrome include:[4]

Treatment

In patients with ACS, and COVID-19 treatment should follow the guideline of the updated Society for Cardiovascular Angiography and Interventions guidelines.[5]


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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [2]; Associate Editor(s)-in-Chief:

Synonyms and keywords: Novel coronavirus, covid-19, COVID-19, SARS-CoV-2, Wuhan coronavirus


Overview

  • COVID-19 patients with cardiovascular comorbidities have higher mortality.
  • Hospitalized patients with COVID-19 and Cardiovascular disease seem to be more prevalent in both the USA and China. [1]
  • In a case series with 187 patients who had confirmed COVID-19, 27.8% of patients had a myocardial injury, which caused cardiac dysfunction and arrhythmias. The result was significantly higher mortality among patients with myocardial injury.
  • It seems to be advisable to triage patients with COVID-19 based on their underlying CVD for a more aggressive treatment plan.
  • The mortality during hospitalization was shown to be 7.62% for patients without underlying CVD and normal TnT levels, 13.33% for those with underlying CVD and normal TnT levels, 37.50% for those without underlying CVD but elevated TnT levels, and 69.44% for those with underlying CVD and elevated TnTs.[6]

Historical Perspective

Classification

ST-Elevation Myocardial Infarction (STEMI)

A US model from 9 major centers showed a 38% drop in total STEMI activations during the COVID-19 pandemic. There is a 40% reduction noted in Spain as well. there was also a delay between the first presentation to a medical encounter up to 318 min. This is important since COVID-19 can potentially be a cause of STEMI through microthrombi, cytokine storm, coronary spasm, or direct endothelial injury.[2]

  • Potential etiologies for the reduction in STEMI PPCI activations:
    • avoidance of medical care due to social distancing or concerns of contracting COVID-19 in the hospital
    • STEMI misdiagnosis
    • increased use of pharmacological reperfusion due to COVID-19

It is very important to realize if patients' anxiety is the reason behind decreasing the presentation of STEMI to U.S. hospitals.[3]

  • Treatment of STEMI & COVID-19: The specific protocols for the treatment have been evolving. Early recommendations showed intravenous thrombolysis as first-line therapy for STEMI patients with confirmed COVID-19 since most hospitals do not have protected cardiac catheterization labs.[2]

Pathophysiology

The mechanism of COVID-19 cardiovascular injury has not been fully understood and is likely multifactorial.

  • SARS-CoV-2 virus attaches to ACE 2 protein for ligand binding before entering the cell via receptor-mediated endocytosis.
    • Based on single-cell RNA sequencing more than 7.5% of myocardial cells have positive ACE2 expression. This protein can mediate the entry of SARS-CoV-2 and result in direct cardiotoxicity.
  • The cytokine release caused by the virus may lead to vascular inflammation, plaque instability, myocardial inflammation, a hypercoagulable state, or direct myocardial suppression.

Pathological changes:

  • In the level of cardiac tissue: minimal change to interstitial inflammatory infiltration and myocyte necrosis
  • In the level of vasculature: micro-thrombosis and vascular inflammation[1]

Diagnosis

Diagnostic study of choice | History and Symptoms | Physical Examination | Laboratory Findings | Electrocardiogram | X-Ray Findings | Echocardiography and Ultrasound | CT-Scan Findings | MRI Findings | Other Imaging Findings | Other Diagnostic Studies

History and Symptoms

The signs and symptoms of acute coronary syndrome include:[4]

Treatment

Medical Therapy | Interventions | Surgery | Primary Prevention | Secondary Prevention | Cost-Effectiveness of Therapy | Future or Investigational Therapies In patients with ACS, and COVID-19, treatment should follow the guidelines of the updated Society for Cardiovascular Angiography and Interventions.[1] [5]

History and Symptoms

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].

Treatment

In patients with ACS, and COVID-19, treatment should follow the guidelines of the updated Society for Cardiovascular Angiography and Interventions.[1] [5]

  1. ↑ 1.0 1.1 1.2 1.3 1.4 Kang Y, Chen T, Mui D, Ferrari V, Jagasia D, Scherrer-Crosbie M; et al. (2020). "Cardiovascular manifestations and treatment considerations in covid-19". Heart. doi:10.1136/heartjnl-2020-317056. PMC 7211105 Check |pmc= value (help). PMID 32354800 Check |pmid= value (help).
  2. ↑ 2.0 2.1 2.2 2.3 Ullah W, Sattar Y, Saeed R, Ahmad A, Boigon MI, Haas DC; et al. (2020). "As the COVID-19 pandemic drags on, where have all the STEMIs gone?". Int J Cardiol Heart Vasc. 29: 100550. doi:10.1016/j.ijcha.2020.100550. PMC 7261452 Check |pmc= value (help). PMID 32550258 Check |pmid= value (help).
  3. ↑ 3.0 3.1 Garcia S, Albaghdadi MS, Meraj PM, Schmidt C, Garberich R, Jaffer FA; et al. (2020). "Reduction in ST-Segment Elevation Cardiac Catheterization Laboratory Activations in the United States During COVID-19 Pandemic". J Am Coll Cardiol. 75 (22): 2871–2872. doi:10.1016/j.jacc.2020.04.011. PMC 7151384 Check |pmc= value (help). PMID 32283124 Check |pmid= value (help).
  4. ↑ 4.0 4.1 4.2 Abidov A, Rozanski A, Hachamovitch R, Hayes SW, Aboul-Enein F, Cohen I; et al. (2005). "Prognostic significance of dyspnea in patients referred for cardiac stress testing". N Engl J Med. 353 (18): 1889–98. doi:10.1056/NEJMoa042741. PMID 16267320. Review in: Evid Based Med. 2006 Jun;11(3):91
  5. ↑ 5.0 5.1 5.2 Szerlip M, Anwaruddin S, Aronow HD, Cohen MG, Daniels MJ, Dehghani P; et al. (2020). "Considerations for cardiac catheterization laboratory procedures during the COVID-19 pandemic perspectives from the Society for Cardiovascular Angiography and Interventions Emerging Leader Mentorship (SCAI ELM) Members and Graduates". Catheter Cardiovasc Interv. doi:10.1002/ccd.28887. PMID 32212409 Check |pmid= value (help).
  6. ↑ Guo T, Fan Y, Chen M, Wu X, Zhang L, He T; et al. (2020). "Cardiovascular Implications of Fatal Outcomes of Patients With Coronavirus Disease 2019 (COVID-19)". JAMA Cardiol. doi:10.1001/jamacardio.2020.1017. PMC 7101506 Check |pmc= value (help). PMID 32219356 Check |pmid= value (help).
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