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Neika Coughlin APRN-BC

COVID-19 Impact

• From January 1, 2020-June 2, 2020:

• Hospitalizations for acute CV conditions have declined

• avoiding hospitals

• deferral of outpt visits, diagnostic studies, semi-elective procedures

• 397,042 CV deaths

• Increased ischemic and HTN related deaths (NYC, NY, NJ, MI, IL)

• 199,311 (1/1/2020-3/17,2020) vs 197, 731 (3/18-6/2, 2020)

• Increased home deaths

• Decreased hospitalizations for MI, HF, CVA

• less cardiac catheterizations and STEMI activations

• Decreased response times, reduction in bystander CPR=decreased survival post cardiac arrest

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SARS-CoV-2 & RAAS

Role of the ACE2 receptor

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Potential Sars-CoV-2 Cardiovascular Effects

COVID -19 Cardiovascular Complications

• ACS/MI NSTEMI type II

• Systolic dysfunction

• Diastolic dysfunction

• Tachycardia

• Hypotension

• Bradycardia

• Paroxsymal atrial fibrillation

• Pulmonary embolism->Acute Cor Pulmonale

• Myocarditis

• Endocarditis

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ACS/MI

• ACS/STEMI

• acute occlusion of coronary artery

• ACS/NSTEMI

• blockage in minor artery or partial obstruction of a major coronary artery

• ST-T changes

• Chest pain

• Elevated hs troponin

• NSTEMI type II

• secondary to ischemia from a supply-demand mismatch

• hypoxia, inflammation, anemia

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hs TroponinWhat Does It Mean?

• Sex specific ranges• Female <=14ng/mL

• Male <=22ng/mL

• hs Troponin is 1000x Troponin T• i.e. hs Troponin 682ng/L = Troponin T 0.68ng/mL

Causes of elevated hs Troponin

• Noncoronary ischemia

• shock

• hypoxia

• hypoperfusion

• PE

• CT surgery

• Myocardial injury with no ischemia

• Renal failure

• sepsis

• infiltrative diseases

• acute respiratory failure

• stroke

• SAH

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Causes of elevated hs Troponin

• Other

• stress cardiomyopathy (Takotsubo)

• myocarditis

• myopericarditis

• rhabomyolysis

• hypertrophic cardiomyopathy

• peripartum cardiomyopathy

• heart failure, malignancy

STEMI

• 1-2mm ST elevation in 2 contiguous leads

• new LBBB

• chest pain

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ACS/NSTEMI

• Chest pain

• ST-T changes• T wave inversion

• ST depression

• Elevated hs troponin

Heart Failure in COVID-19Systolic Heart Failure

• Systolic heart failure• Acute/acute on chronic

• Due to MI, myocarditis

• Stress cardiomyopathy (Takotsubo)• Hypoxia

• Infection

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Systolic Heart Failure

• Diurese cautiously

• Guideline directed therapy• Beta blockers

• ACE/ARB/ARNI• Entresto

• Spironolactone

Systolic Heart Failure Treatment at Discharge

• Guideline directed therapy as BP and renal function allow:• Beta blockers

• ACE/ARB/ARNI• Entresto

• Spironolactone

• Consider device therapy/LifeVest, if indicated

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Heart Failure in COVID-19Diastolic Heart Failure

• Elderly, especially females

• Hypertension

• Tachycardia• Sinus tachycardia

• Atrial Fibrillation with RVR

• Hypoxia

Heart Failure in COVID-19

• Acute cor pulmonale• Right heart failure caused by sudden increase in resistance to blood flow in the

pulmonary circulation• Pulmonary embolism

• COPD

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Acute Cor PulmonaleCauses

• Pulmonary embolus

• ARDS

• RV infarction

• Myocarditis

• COPD

Acute Cor PulmonalePresentation

• Chest pain

• Dyspnea

• Tachypnea

• Hypoxia

• Hypotension

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Acute Cor PulmonaleDiagnosis

• elevated d-dimer

• elevated hs Troponin

• ST-T changes

• elevated proBNP

• RV dysfunction on echo• Elevated pulmonary artery systolic pressure (RVSP > 25mmHg)

Acute Cor PulmonaleTreatment

• Treat underlying cause

• Maintain adequate preload• Fluids for hypotension

• Vasopressors

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MyocarditisCauses

• SARS-CoV-2

MyocarditisInflammatory disease of the Myocardium

• Hx of viral infection within the past 3-4 weeks (COVID long haulers)

• Fatigue

• Progressive dyspnea

• Fever

• Myalgias

• chest pain

• heart failure

• Cardiogenic Shock

• Arrhythmias

• Sudden death

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MyocarditisDiagnosis

• EKG

• hs Troponin

• proBNP

• CBC-> increased eosinophils

• ESR/hsCRP

• CXR

• Echocardiogram

• Cardiac catheterization -> myocardial biopsy

• Cardiac MRI

MyocarditisTreatment

• Treat cause

• If decreased LV function begin guideline directed therapy

• Treat arrhythmias

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Arrhythmias

• Paroxysmal atrial fibrillation

• Bradycardia• Sinus bradycardia

• Heart block

• Tachycardia

• Ventricular arrhythmias

Paroxysmal Atrial FibrillationPAF

• Increased risk with age alone

• Increased risk with:• pulmonary disease

• hypoxia

• acute illness

• infection

• pulmonary emboli

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PAFTreatment

• Atrial fibrillation protocol

• Identify underlying cause

• CHA2DS2-VASc score

• Anti-coagulation for Stroke prevention

BradycardiaSinus bradycardia, Heart blocks

• Myocarditis with inflammation of the electrical conduction system

• Medications• Beta blockers

• Calcium channel blockers

• Precedex

• Hypoxia

• Increased vagal tone

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Bradyarrhythmias

• Treat cause

• Adjust medications• If pt hemodynamically stable, continue to monitor

• If heart block and asymptomatic, monitor for progression• Consider pacemaker

Sinus Tachycardia

• Compensatory mechanism

• Allow permissive tachycardia

• Treat underlying cause

• Fever

• Hypoxia

• Infection

• Diurese

• Pain

• Anemia

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Ventricular ArrhythmiasPVCs, Ventricular Tachycardia, Ventricular Fibrillation

• Occur in the presence of:• ACS

• Heart failure

• Myocarditis

Ventricular ArrhythmiasTreatment

• ACLS protocols acutely

• Amiodarone

• If EF < 35%, consider LifeVest vs ICD prior to discharge

• Hydroxychloroquine• QT prolongation

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Potential Sars-CoV-2 Cardiovascular Effects

Questions