Gregory Weiss, MD

It has been nearly 2 years since the first cases of clinical COVID-19 were identified. Since then, the novel coronavirus has infected tens of millions of people worldwide and led to unprecedented mortality and morbidity. Through it all colleges and societies of cardiologists have raced to keep up with the cardiovascular implications of exposure and infection with COVID-19. The European Society of Cardiology (ESC) has kept pace studying the data and issuing recommendations for the diagnosis and treatment of CVD during the pandemic.

Most recently the ESC has issued guidance with regards to care pathways, treatment, and follow-up for patients presenting with cardiovascular conditions during the COVID-19 pandemic. This latest guide produced by The Task Force for the Management of COVID-19 of the European Society of Cardiology represents the second part of a two-part series addressing care of the cardiovascular patient during the pandemic. In this part they specifically address care pathways, treatment plans, and following up after discharge.

Care Pathways and Treatment Plans

Diagnosis and Treatment of Patients with Suspected Acute Coronary Syndromes:

Cardiogenic Shock:

• The management of cardiogenic shock and out-of-hospital cardiac arrest are critically time-dependent conditions requiring prompt standardized care with multidisciplinary expertise.
• Established, standardized protocols including selection for mechanical circulatory support (MCS) should continue to be employed.
• Invasive coronary angiography (ICA) remains the mainstay of treatment. However, special considerations need to be considered to minimize the risk of widespread nosocomial infections.
• If patients have COVID-19, escalation to MCS, should be weighed against possible coagulopathy and need for prone positioning.
• Extracorporeal Membrane Oxygenation (ECMO) should be the preferred temporary MCS due to oxygenation capabilities.
• Continuous renal replacement therapy (CRRT) should be used restrictively for acute renal failure.
• Daily organ failure assessments should be made to determine which patients are most critical.
• Promoting the safety of health care providers is of predominant importance.
• COVID-19 infection should be excluded through two negative tests.
• Prone patients may receive CPR in the prone position if technically challenging to place supine.

ST-Segment Elevation Myocardial Infarction:

• The maximum delay from STEMI diagnosis to reperfusion should remain 120 minutes.
• If COVID-19 test results are not available immediately, the patient should be considered infected.
• All STEMI patients should undergo COVID-19 testing as soon as possible.
• Consider immediate complete revascularization if indicated to avoid staged procedures.
• Physicians should be familiar with fibrinolysis protocols.

Chronic Coronary Syndromes

• Generally low risk for CV events, may defer diagnostic and or interventional procedures, in most cases.
• Optimize medical therapy.
• Utilize remote clinical follow-up when possible.

Non-Coronary Syndromes

Heart Failure (HF)

• Acute HF may complicate the course of COVID-19.
• HF may arise from many root causes including acute myocarditis from COVID-19.
• COVID-19 pneumonia may worsen hemodynamic status.
• Symptoms of COVID-19 and worsening HF are similar. Consider point of care echocardiography.
• Treatment of HF in COVID-19 patients should be the same as in non-COVID-19 patients.

Myocarditis

• Myocarditis is rare but seen in some COVID-19 patients.
• Myocarditis may be present in COVID-19 patients without respiratory symptoms.
• It should be suspected in patients with acute onset chest pain or other cardiac symptoms/signs.
• Myocardial biopsy is not recommended in COVID-19 patients routinely.

Aortic Stenosis, Mitral Regurgitation

• Both conditions should be managed conservatively unless symptomatic and urgent intervention is needed.
• Non-urgent procedures should be deferred.

Hypertension

• Should be treated with existing recommendations with no change.

Acute Pulmonary Embolism (PE)

• Prompt anticoagulation should not be delayed. Use existing guidelines.

Arrhythmias

• Arrhythmias may complicate COVID-19 infection and are a poor prognostic sign.
• They should be treated with existing guidelines keeping in mind drug interactions with therapies used for COVID-19.
• Amiodarone is the drug of choice for hemodynamically unstable tachy-arrhythmias.
• For the most part arrhythmias should be treated according to established guidelines.

Treatment of SARS-CoV-2 Infection

• The evidence regarding the efficacy and risk of different treatment strategies in patients with COVID-19 is extensive and continuously evolving; the current and regularly updated version of the World Health Organization (WHO) ‘living guidelines’ is online available.
• Recent randomized clinical trials suggest that, with the exception of glucocorticoids (especially dexamethasone) in hospitalized patients with severe and critical COVID-19, the majority of the initially used antiviral, anti-inflammatory, or immunomodulatory experimental drugs have no or limited effect on the natural history of COVID-19.
• In all patients undergoing antiviral treatment, it is of major importance to correct modifiable predisposing factors to QTc prolongation: electrolyte imbalances, concomitant drugs, and bradycardia.

Post-Infection Education and Follow-up

• Transparent patient centered information is essential to support patients and reduce transmission risk.
• Pre-existing CVD has a direct impact on COVID-19 disease and survival.

Patients should be counseled to avoid sick people, practice social distancing, proper hand washing techniques and frequency, covering their mouth and nose when coughing, avoidance of touching their faces, and surface decontamination techniques.

Patients should be told to self-isolate in case of symptoms but when healthy they should engage in physical activity and maintain well-being.

Finally, patients with CVD should continue to practice healthy lifestyle behaviors. They should not smoke, they should avoid inactivity, and they should attend any clinical appointments with an emphasis on telehealth visits when feasible. As clinicians we should encourage our patients to keep up with their medication regimen and unless contraindicated, get vaccinated for COVID-19.

While the most salient points contained within the ESC recommendations have been relayed here the sheer volume of information was beyond the brevity and scope of this review. The entirety of the recommendations can be found here.

Reference:

ESC guidance for the diagnosis and management of cardiovascular disease during the COVID-19 pandemic: part 2—care pathways, treatment, and follow-up. Eur Heart J. 2021. doi:10.1093/eurheartj/ehab697.