Multimodality Imaging in Cardiovascular Complications of COVID-19

Rudski L, Januzzi JL, Rigolin VH, et al., on behalf of the Expert Panel From the ACC Cardiovascular Imaging Leadership Council.
Multimodality Imaging in Evaluation of Cardiovascular Complications in Patients With COVID-19: JACC Scientific Expert Panel. J Am Coll Cardiol 2020;76:1345-1357.

The following are key points to remember from the expert panel statement on multimodality imaging in evaluation of cardiovascular complications in patients with coronavirus disease 2019 (COVID-19):

  1. Elevations of cardiac troponin (cTn), as well as B-type natriuretic peptide (BNP) and N-terminal pro-BNP (NT-proBNP), are strong negative prognostic indicators in COVID-19, particularly when values are markedly elevated and rise during hospitalization. However, most patients with abnormal BNP/ NT-proBNP and cTn do not have heart failure (HF) or myocardial infarction (MI), but rather myocardial stress/injury in the setting of systemic illness. Mildly elevated, nonrising BNP/NT-proBNP and cTn may help exclude the need for cardiac imaging.
  2. Initial diagnostic evaluation of patients with COVID-19 with suspected cardiac involvement should include history and physical, electrocardiogram (ECG), and chest X-ray, and biomarkers. When cardiac imaging is clinically indicated and is expected to change management, point-of-care cardiac ultrasound (POCUS) or limited echocardiogram should be first-line techniques.
  3. When the clinical presentation is consistent with ST-elevation MI (STEMI) or high-risk acute coronary syndrome (ACS), referral for emergent coronary angiography and reperfusion therapy is appropriate. When ECG and symptoms are equivocal for ACS, an urgent, focused echocardiogram to assess for regional wall motion abnormalities is reasonable; depending upon results, invasive angiography or computed tomography coronary angiography (CTCA) may then be pursued. For patients with previously known coronary artery disease (CAD), CTCA may be more difficult to interpret due to coronary calcifications, and pharmacological stress imaging (preferably vasodilator cardiovascular magnetic resonance [CMR] or nuclear imaging) is recommended. CMR can be useful for distinguishing the mechanism of myocardial injury in patients with MI with nonobstructive coronary arteries (MINOCA).
  4. In the setting of hemodynamic instability, POCUS or focused echocardiogram is recommended to assess for left ventricular (LV) and right ventricular (RV) systolic dysfunction, regional wall motion abnormalities, and pericardial effusion. Myocarditis and myocardial injury can present with regional wall motion abnormalities, so if clinical suspicion for type I MI is low, CTCA may be preferred over invasive angiography. For patients with RV dysfunction, contrast-enhanced chest CT is the modality of choice to assess for pulmonary embolism.
  5. In the setting of newly discovered LV dysfunction without hemodynamic instability, if an echocardiogram demonstrates LV dilation and wall thinning, a pre-existing cardiomyopathy is likely, and further imaging may be pursued nonurgently. If the LV is nondilated and wall motion abnormalities are diffuse or present in a noncoronary distribution, myocarditis or stress cardiomyopathy is likely, and further imaging may include repeat echocardiogram in 3-7 days, CMR, or positron emission tomography (PET).
  6. In the subacute and chronic phases of COVID-19, nonspecific symptoms including dyspnea and fatigue are common, and the differential diagnosis for such complaints is broad. For patients with LV dysfunction discovered during the acute phase, repeat echocardiogram or CMR 2-6 months following discharge may be considered, and guideline-directed medical therapy for HF should be optimized. Workup for new syncope, significant palpitations, and chest discomfort should proceed based on current guidelines.
  7. Transesophageal echocardiography is an aerosol-generating procedure and should be avoided during the acute phase of COVID-19 if possible. In general, strict adherence to infection control policies is required to minimize risk of COVID-19 exposure and transmission to health care workers and patients without COVID-19 who are referred for imaging.

Clinical Topics: Acute Coronary Syndromes, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Pericardial Disease, Stable Ischemic Heart Disease, Vascular Medicine, Atherosclerotic Disease (CAD/PAD), ACS and Cardiac Biomarkers, Acute Heart Failure, Heart Failure and Cardiac Biomarkers, Interventions and ACS, Interventions and Coronary Artery Disease, Interventions and Imaging, Interventions and Vascular Medicine, Angiography, Computed Tomography, Echocardiography/Ultrasound, Magnetic Resonance Imaging, Nuclear Imaging, Chronic Angina

Keywords: Acute Coronary Syndrome, Cardiomyopathies, Coronary Angiography, Coronary Artery Disease, Coronavirus, COVID-19, Diagnostic Imaging, Echocardiography, Echocardiography, Transesophageal, Electrocardiography, Heart Failure, Magnetic Resonance Imaging, Myocardial Infarction, Myocarditis, Natriuretic Peptide, Brain, Pericardial Effusion, Positron-Emission Tomography, Pulmonary Embolism, ST Elevation Myocardial Infarction, Syncope, Takotsubo Cardiomyopathy, Troponin, Tomography, Ultrasonography, Ventricular Dysfunction

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