DALLAS, April 4, 2020 — Research to help increase awareness of the cardiovascular manifestations of COVID-19 disease and the adverse impact of cardiovascular involvement on prognosis was published late yesterday in Circulation, the flagship journal of the American Heart Association.
In The Variety of Cardiovascular Presentations of COVID-19, the team of 18 New York City physicians note COVID-19 can involve the cardiovascular system in a variety of ways, and there are evolving considerations for treatment across the spectrum of patients with preexisting cardiovascular diseases. The researchers also detail four case studies of patients to illustrate the multiple cardiovascular presentations of COVID-19 infection.
The authors’ take-home messages are:
- In patients presenting with what appears to be a typical cardiac syndrome, COVID-19 infection should be in the differential during the current pandemic, even in the absence of fever or cough.
- One should have a low threshold to assess for cardiogenic shock in the setting of acute systolic heart failure related to COVID-19. If inotropic support fails in these patients, we consider IABP [intraaortic balloon pump] as the first line mechanical circulatory support device because it requires the least maintenance from medical support staff.
- When patients on VV ECMO, veno-venous extracorporeal membrane oxygenation, for respiratory support develop superimposed cardiogenic shock, the addition of an arterial conduit at relatively low blood flow rates may provide the necessary circulatory support without inducing LV distension. Our experience confirms that rescue of patients even with profound cardiogenic or mixed shock may be possible with temporary hemodynamic support at centers with availability of such devices.
- COVID-19 infection can cause decompensation of underlying heart failure, and may lead to mixed shock. Invasive hemodynamic monitoring, if feasible, may be helpful to manage the cardiac component of shock in such cases.
- Medications that prolong the QT interval are being considered for COVID-19 patients and may require closer monitoring in patients with underlying structural heart disease.
- Our heart transplant recipient exhibited similar symptoms of COVID-19 infection as compared to the general population.
- For those transplant patients requiring hospitalization, how to alter the anti-metabolite and immunosuppression regimens remains uncertain.
- Furthermore, the COVID-19 pandemic creates a challenge for the management of heart failure patients on the heart transplant waitlist, forcing physicians to balance the risks of delaying transplant with the risks of donor infection and uncertainty regarding the impact of post-transplant immunosuppression protocols.
Co-authors include Justin A. Fried, M.D.; Kumudha Ramasubbu, M.D.; Reema Bhatt, M.D.; Veli K. Topkara, M.D., M.Sc.; Kevin J. Clerkin, M.D., M.Sc.; Evelyn Horn, M.D.; LeRoy Rabbani, M.D.; Daniel Brodie, M.D.; Sneha S. Jain, M.D., M.B.A.; Ajay Kirtane, M.D., S.M.; Amirali Masoumi, M.D.; Koji Takeda, M.D., Ph.D.; Deepa Kumaraiah, M.D., M.B.A.; Daniel Burkhoff, M.D., Ph.D.; Martin Leon, M.D.; Allan Schwartz, M.D.; Nir Uriel, M.D.; M.Sc.; and Gabriel Sayer, M.D.
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