CVD in the Setting of COVID-19: Considerations to Prepare Patients, Providers, Health Systems
Test The cardiovascular community will be on the frontlines and play a key role in managing and treating patients with COVID-19. In a paper published March 19 in the Journal of the American College of Cardiology, considerations for patients, providers and health systems now and during the COVID-19 pandemic are outlined, along with a review of what's currently known from the available literature about this disease and its cardiovascular impacts, as well as the gaps in knowledge.
A close clinical interplay between SARS-CoV2 and cardiovascular disease processes has been suggested by data from early cohorts with COVID-19. Preexisting cardiovascular disease has been associated with poor outcomes with COVID-19 infection, and though cases are limited, direct cardiovascular effects of the virus have been observed and may be associated with significant morbidity and mortality, write the authors.
Looking at the prevalence of cardiovascular disease in patients with COVID-19, a meta-analysis with 1,527 patients revealed hypertension in 17.1%, composite of cardiac and cerebrovascular disease in 16.4%, and diabetes in 9.7%. Preexisting hypertension was associated with a risk ratio of 2.03 for ICU admission.
The authors review current data on the cardiovascular sequalae associated with COVID-19: myocardial injury, myocarditis, and acute coronary syndromes; cardiac arrhythmia and sudden cardiac death; cardiomyopathy and heart failure; cardiogenic and mixed shock; and venous thromboembolic disease.
Currently there is no definite treatment for COVID-19. The authors, however, review the potential cardiovascular side effects and interactions with other cardiovascular medications of various pharmacologic agents that have been identified as potential treatment options and are currently under investigation. Notably, they also highlight the current discussion about the role of the ACE2 receptor and the ongoing debate about the implications of ACE inhibitor and angiotensin-receptor blocker therapy in patients with COVID-19.
Among considerations for providers is personal protective equipment (PPE) and triaging cardiovascular patients and visits. Importantly, beyond the standard contact precautions, special consideration should be given for protection in the setting of aerosol-generating procedures, such as transesophageal echocardiography or mechanical ventilation, which may require additional PPE. For cardiac arrest and chest compressions, providers can consider as much as possible the use of external mechanical compression devices to minimize direct contact with patients.
Telehealth will be an important tool for patient triage to minimize potential exposure to providers and other patients, and to provide for the involvement of a specialist in care that otherwise may not have been available.
Finally, considerations for health systems reviewed include preparing for hospital surges and prioritizing care for the critically ill; appropriate use of PPE to limit shortages; and need for education, including the need for the free flow of communication between hospitals and health care providers across the spectrum that will be required for the care of COVID-19 patients, including the cardiovascular care team, pulmonology/critical care, infectious diseases and pharmacists.
Clinical Topics: Acute Coronary Syndromes, Arrhythmias and Clinical EP, COVID-19 Hub, Heart Failure and Cardiomyopathies, Noninvasive Imaging, Prevention, Vascular Medicine, Implantable Devices, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias, Acute Heart Failure, Echocardiography/Ultrasound, Hypertension
Keywords: Coronavirus, Coronavirus Infections, COVID-19, Cardiovascular Diseases, Peptidyl-Dipeptidase A, Myocarditis, Critical Illness, Pulmonary Medicine, Acute Coronary Syndrome, Echocardiography, Transesophageal, Respiration, Artificial, Severe Acute Respiratory Syndrome, Death, Sudden, Cardiac, Angiotensin-Converting Enzyme Inhibitors, Cardiovascular Agents, Heart Failure, Arrhythmias, Cardiac, Hypertension, Cardiology, Diabetes Mellitus, Telemedicine, Critical Care, Cerebrovascular Disorders, Angiotensin Receptor Antagonists, Intensive Care Units
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