COVID-19 Clinical Guidance for Cardiovascular Care Teams

COVID-19 is a rapidly evolving public health emergency. The guidance provided in this document is based on the best available published information and expert evaluation. This document is intended to supplement, not replace, relevant guidance from the Centers for Disease Control and Prevention, state and local health authorities, and your institution’s infectious disease containment, mitigation, and response plan .

To better serve your patients: Protect yourself first!

This is especially true for professionals on the cardiovascular care team who will be on the front lines of the COVID-19 response. Use masks, gloves and other personal protective equipment with discipline. Wash hands frequently. Decontaminate surfaces frequently including stethoscope, cell phones, computer peripherals, and other devices.

Current COVID-19 Clinical Context

• The overall case fatality rate (CFR) of COVID-19 based on published reports remains low at 2.3% , with data indicating lower overall Chinese mortality outside the outbreak epicenter in Hubei, China .

• Beyond China, real-time reports indicate CFR between 2.7% (Iran) and 0.5% (South Korea); however, this information is provisional and is likely to change.

• More than 80% of infected patients experience mild symptoms and recover without intensive medical intervention.

• However, morbidity and mortality increase significantly with age, reaching 8.0% among patients 70-79 and 14.8% in patients older than 80 years in large-scale Chinese case reports.

• Published case reports from the China Centers for Disease Control indicate patients with underlying comorbid conditions have an elevated risk of contracting COVID-19 and a worse prognosis; According to the report, between 25% and 50% of COVID-19 patients have underlying conditions.

• Case fatality rates for comorbid patients are materially higher than the average population:

o Cancer: 5.6%
o Hypertension: 6.0%
o Chronic respiratory disease: 6.3%
o Diabetes: 7.3%
o Cardiovascular disease: 10.5%

Acute cardiac complications of COVID-19

• In a recent case report on 138 patients hospitalized with COVID-19, 16.7% of patients developed arrhythmia and 7.2% experienced acute cardiac injury in addition to other COVID-19-related complications.

• Published and anecdotal reports indicate cases of acute-onset heart failure, myocardial infarction, myocarditis, and cardiac arrest; As with any acute illness, increased cardiometabolic demand can precipitate cardiac complications.

• The current report does not yet describe the prevalence of cardiac complications in patients with recent CVD versus patients with cardiac comorbidity.

• Cardiac complications of COVID-19 are approximately proportional to SARS, MERS, and influenza analogues.

• Cardiologists must be prepared to assist other clinical specialties in managing cardiac complications in severe cases of COVID-19.

• Critical care and cardiology teams should consult to guide the care of patients requiring extracorporeal circulatory support with veno-venous (VV) versus veno-arterial (VA) ECMO.

• Patients who demonstrate heart failure, arrhythmia, ECG changes, or cardiomegaly should undergo echocardiography .

COVID-19 Implications for Patients with Underlying Cardiovascular Conditions

• Make plans to quickly identify and isolate cardiovascular patients with COVID19 symptoms from other patients, including in the outpatient setting.

• Patients with underlying cardiovascular disease are at higher risk of contracting COVID-19 and have a worse prognosis.

• It is reasonable to inform all cardiovascular patients of the possible increased risk and to encourage additional reasonable precautions in accordance with CDC guidance.

• It is important for patients with CVD to remain up-to-date on vaccinations , including the pneumococcal vaccine given the increased risk of secondary bacterial infection with COVID-19; Patients with CVD should be vaccinated against influenza according to current ACC/AHA guidelines.

• In geographies with active COVID-19 outbreaks, it may be reasonable to substitute routine in-person visits for stable CVD patients with telephone or telehealth visits to avoid potential nosocomial COVID-19 infection; Planning for emergency telehealth protocols must begin now.

• It is reasonable to classify COVID-19 patients according to underlying cardiovascular, diabetic, respiratory, renal, oncological or other comorbidities for priority treatment.

• Providers are cautioned that the classic symptoms and presentation of AMI may be overshadowed in the context of COVID-19, resulting in underdiagnosis. • For patients with heart failure or volume overload

conditions , copious fluid administration for viral infection should be used with caution and carefully monitored. • Overall immune health remains important for both providers and patients, including eating well, sleeping, and managing stress.

COVID-19 Specific Cardiac Preparedness Recommendations

• In some settings, the cardiovascular care team (including physicians, nurses, technicians, etc.) may have limited training and experience in the acute management of pandemic disease; The routine transmission of COVID-19 to healthcare workers suggests that daily infectious disease mitigation precautions are insufficient and that healthcare workers in outbreak areas should be prepared to adopt personal protective measures.

• Protocols for the diagnosis, classification, isolation and management of COVID-19 patients with cardiovascular complications and/or cardiovascular patients with COVID-19 should be developed in detail and tested; CV-specific plans should be developed in collaboration with hospital-wide infectious disease response plans and in close collaboration with other medical specialties.

• Cardiovascular care team members with limited experience and/or training in donning, using, and doffing personal protective equipment (PPE) should be trained now in accordance with CDC guidance .

• Specific protocols for the treatment of AMI in the context of a COVID-19 outbreak should be developed, both for patients with and without a diagnosis of COVID-19.

o Special emphasis should be placed on acute angioplasty (PCI) and coronary artery bypass grafting (CABG), including protocols to limit cath lab and operating room personnel to a required minimum, predetermined requirements for better personal protection, and evaluate the adequacy of post-procedural sterilization.

o In extreme circumstances, clinical leadership may need to evaluate the risk-benefit ratio of acute myocardial infarction intervention (given limited data on the primary benefit of PCI for type 2-MI acute viral disease) against the risk of nosocomial infection.

bibliographical references

The Epidemiological Characteristics of an Outbreak of 2019 Novel Coronavirus Disease (COVID-19). China CDC Weekly 2020. 2(8): 1
Coronavirus COVID-19 Global Cases by Johns Hopkins CSSE (March 3, 2020)
Chen H, Zhou M, Dong X, et al. Epidemiological and Clinical Characteristics of 99 cases of 2019 novel coronavirus. Pneumonia in Wuhan, China: a descriptive study. Lancet 2020; published online January 29 .
Wang D, Hu B, Hu C, et al.Clinical Characteristics of 138 Hospitalized Patients with2019 Novel Coronavirus-Infected Pneumonia in Wuhan, China. JAMA. Published online February 07, 2020. doi:10.1001/jama.2020.1585

COVID-19 Clinical Guidance for Cardiovascular Care Teams

A comprehensive guide outlining strategies for addressing cardiovascular pathologies within the clinical context of COVID-19, providing essential guidance for healthcare professionals managing patients with both cardiovascular disease and COVID-19.