Jaya Mallidi, MD

Disclosures

March 26, 2020

Jaya Mallidi, MD, MHS

We are in the midst of a pandemic. Yet cardiologists outside the hot geographical zones probably have not yet had direct encounters with hospitalized patients with confirmed coronavirus disease of 2019 (COVID-19). However, the surge is coming, and we will soon see many of them.

Most of our current knowledge is limited to the experience from China. The cardiovascular (CV)  manifestations directly related to COVID-19 include myocarditis, myocardial injury, acute coronary syndrome, cardiomyopathy, congestive heart failure, cardiogenic shock, fatal arrhythmias, and thromboembolic disease. Based on the limited data so far, approximately 10% of hospitalized patients with COVID-19 have underlying CV disease. The number of patients who develop CV sequelae from COVID-19 varies. As cardiology physicians on the frontline, we will be called on to help emergency department physicians, hospitalists, and intensivists in the coming weeks and months.

Below is a summary of the guidance so far from literature review and the CV professional societies:

Troponin: Mild elevation of troponin, especially regarding high-sensitivity troponin in hospitalized patients with COVID-19, is common and nonspecific. Unless symptoms, electrocardiogram (ECG), or echocardiogram findings corroborate clinical suspicion of acute myocardial infarction or myocarditis, ordering "routine troponins for all patients" or testing based on mild, nonspecific elevation (MI) should be avoided.  

Myocarditis and acute MI: Severely and critically ill patients with COVID-19 can develop myocardial injury with significantly elevated cardiac biomarkers due to nonischemic causes (such as myocarditis) or ischemic causes (both type 1 MI, with plaque rupture, and type 2 MI, with supply/demand mismatch) in the setting of hypoxia from acute respiratory distress syndrome and potential microthrombi. Case reports describe patients with COVID-19 presenting with ECG findings suggesting non–ST-elevation MI (non-STEMI) without obstructive coronary artery disease. According to guidance from the American College of Cardiology's Interventional Council and Society for Cardiovascular Angiography & Interventions, thrombolytic therapy may be considered in stable patients with COVID-19 and STEMI and suspicion of type 1 MI. Depending on institutional practices and availability of adequate personal protective equipment (PPE), activating the catheterization lab may be prudent—the differential diagnosis is broad, including conditions that do not require treatment with percutaneous coronary intervention or thrombolytic therapy.

Cardiomyopathy and heart failure: Among severely and critically ill hospitalized patients with COVID-19, 23% to 33% develop cardiomyopathy and associated heart failure, requiring supportive management.

Arrhythmias and cardiogenic or mixed shock: Critically ill patients with COVID-19 can develop cardiac arrhythmias and profound cardiogenic or mixed shock that require mechanical respiratory and circulatory support with extracorporeal membranous oxygenation. These patients have an extremely high mortality rate.

Protect Yourself

Being on-call in the COVID-19 era is different. From now on, every decision we make has to balance the risk for exposure and spreading the infection against the benefit of any test or procedure for the individual patient. As we brace ourselves for the surge, each of us should be aware of national and local prevalence trends and national, state, and institutional response plans. But above all, WE NEED TO PROTECT ourselves. There are reports of healthcare staff working with inadequate protection getting infected, resulting in severe illness  and even death. Protecting ourselves is akin to the directive during an in-flight emergency: "Put your oxygen mask on first before helping others." If we don't, we risk not only getting infected but also spreading the infection to our family members, colleagues, and patients, ultimately undermining the entire mitigation process.

It is disconcerting to see the visuals from China, where the frontline staff are in hazmat suits, while the latest Centers for Disease Control and Prevention recommendations  are lax in a strategy to conserve the supplies in the United States. As we continue to voice our concerns regarding the shortage of PPE supplies and learn lessons from other countries on protecting healthcare staff, every one of us needs to know our institutional PPE recommendations. On the basis of the local prevalence of COVID-19 and the availability of PPE, institutions vary. Unless government officials and hospital administrators figure out ways to increase PPE supply, the harsh reality is that some of us may become sick and even die.

In the COIVD-19 era, PPE includes surgical/preprocedural masks, N-95 respirator masks, face shields, eye protection goggles, gowns, glove, and powered air-purifying respirator (PAPR) or controlled air-purifier respirator (CAPR) systems. Depending on the situation, we may have to don one or all of the above. The infectious disease mitigation precautions we practiced before COVID-19 are insufficient in this pandemic. Instead:

  • Take the time to read the information from your institution regarding the use, reuse, and conservation of PPE and train in both donning and doffing of PPE. You need to know this NOW and not wait for the day of your call. Given the avalanche of COVID-19 emails, create a separate folder specifically for PPE documents so they are easily accessible.

  • All of us should have the N-95 mask fit-testing done. For those doing transesophageal echocardiography, learn how to use PAPR and CAPR systems and use them if available.

  • On the day of call, touch base with the catheterization lab manager early on to make sure there is an adequate supply of PPE for the call team. You do not want to be in a situation where there is a patient with STEMI suspected of having COVID-19 and no PPE is available.

  • Anticipate longer terminal cleaning and plan accordingly. Most cardiac catheterization labs are not negative-pressurized rooms; they need terminal cleaning after any procedures on a patient with suspected or confirmed COVID-19.

  • Diligently wash your hands, and decontaminate frequently used objects, such as cell phones and stethoscopes.

  • Embrace telehealth; reimbursement models can be figured out later.

  • Encourage virtual departmental meetings to discuss issues, such as cancellation of elective procedures, PPE requirements, tough clinical situations (such as acute MI among patients with COVID-19), and to share your learning and experience.

  • If you are not on social media, I suggest joining now. Twitter is a great avenue for staying updated on COVID-19. "Twitter Best Practices and Tips for Physicians" from Johns Hopkins University is a resource-full document for new users.

This is an unprecedented situation—many of us are facing a global pandemic for the first time. We will be learning more each day, so please share your experiences by posting them on social media (#COVID19, #CardioTwitter) because we're all in this fight together.

Jaya Mallidi is an interventional cardiologist in Santa Rosa, California. An ardent patient advocate, she writes opinion pieces using patient stories as context to highlight problems in the practice of modern-day medicine. In addition, she enjoys digital sketching and playing tennis.

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