ACC Guidance on Cardiac Implications of Coronavirus

Susan Jeffrey

February 13, 2020

UPDATED with comments  February 14, 2020 //   The American College of Cardiology (ACC) today released a clinical bulletin that aims to address cardiac implications of the current epidemic of the novel coronavirus, now known as COVID-19.

The bulletin, reviewed and approved by the college's Science and Quality Oversight Committee, "provides background on the epidemic, which was first reported in late December 2019, and looks at early cardiac implications from case reports," the ACC notes in a press release. "It also provides information on the potential cardiac implications from analog viral respiratory pandemics and offers early clinical guidance given current COVID-19 uncertainty."

"The COVID-19 is a likely public health threat and has a high potential to affect US patients in the near future," Mohammad Madjid, MD, an expert advisor for the document, told | Medscape Cardiology. "When dealing with emerging infections, we need to 'prepare for the worst and hope for the best.' "

Preliminary reports suggest that a high proportion of COVID-19 patients have baseline cardiovascular disease, added Madjid, an assistant professor of medicine at McGovern Medical School, University of Texas at Health Science Center at Houston. "We know that viral infections such as influenza can destabilize and worsen cardiac conditions and we expect that COVID-19 will have some effect as well. The cardiovascular effects will not be uniform and will have varying severity in different patients." 

"We will continue monitoring the situation to identify the true cardiovascular impact of COVID-19 and to identify the high-risk patients and come up with relevant clinical recommendations," Madjid added.

For now, the document looks at some early cardiac implications of the infection. For example, early case reports suggest patients with underlying conditions are at higher risk of complications or mortality from the virus, with up to 50% of hospitalized patients having a chronic medical illness, the authors write.

Forty percent of hospitalized patients confirmed to have the virus have cardiovascular or cerebrovascular disease, they note.  

In a recent case report on 138 hospitalized COVID-19 patients, they note, 19.6% developed acute respiratory distress syndrome, 16.7% developed arrhythmia, 8.7% developed shock, 7.2% developed acute cardiac injury, and 3.6% developed acute kidney injury. "Rates of complication were universally higher for ICU patients," they write.

"The first reported death was a 61-year-old male, with a long history of smoking, who succumbed to acute respiratory distress, heart failure, and cardiac arrest," the document notes. "Early, unpublished first-hand reports suggest at least some patients develop myocarditis."

Stressing the current uncertainty about the virus, the bulletin provides the following clinical guidance:  

• COVID-19 is spread through droplets and can live for substantial periods outside the body; containment and prevention using standard public health and personal strategies for preventing the spread of communicable disease remains the priority

• In geographies with active COVID-19 transmission (mainly China), it is reasonable to advise patients with underlying cardiovascular disease of the potential increased risk and to encourage additional, reasonable precautions

• Older adults are less likely to present with fever, thus close assessment for other symptoms such as cough or shortness of breath is warranted

• Some experts have suggested that the rigorous use of guideline-directed, plaque stabilizing agents could offer additional protection to cardiovascular disease (CVD) patients during a widespread outbreak (statins, beta blockers, ACE inhibitors, acetylsalicylic acid); however, such therapies should be tailored to individual patients

• It is important for patients with CVD to remain current with vaccinations, including the pneumococcal vaccine, given the increased risk of secondary bacterial infection; it would also be prudent to receive influenza vaccination to prevent another source of fever which could be initially confused with coronavirus infection

• It may be reasonable to triage COVID-19 patients according to the presence of underlying cardiovascular, respiratory, renal, and other chronic diseases for prioritized treatment

• Providers are cautioned that classic symptoms and presentation of AMI may be overshadowed in the context of coronavirus, resulting in underdiagnosis.

• For CVD patients in geographies without widespread COVID-19, emphasis should remain on the threat from influenza, the importance of vaccination and frequent handwashing, and continued adherence to all guideline-directed therapy for underlying chronic conditions

• COVID-19 is a fast-moving epidemic with an uncertain clinical profile; providers should be prepared for guidance to shift as more information becomes available.

The full clinical update is available here.

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