Management of Patients During COVID-19 Crisis: Focus on Cardiovascular Complications

April 14, 2020

During this call on April 10, 2020 with Global Medical Directors, Dr. Seth Bilazarian focuses on management of cardiovascular complications in patients during the COVID-19 crisis. Slides can be found here on the Acute Cardiac Unloading and Recovery (A-CURE) website.

Early in the call, Dr. Bilazarian highlights a timeline projecting it will likely be June or July before COVID-19 cases near zero and he emphasizes the importance of caring for patients with COVID-19 as well as the increasing problem of patients having to wait for care. “We’re hearing increasingly around the country, patients dying from aortic stenosis waiting for their TAVR, patients with advanced coronary disease who are slated for high-risk intervention or surgical bypass, are, unfortunately, succumbing to the disease because they can’t wait.”

In “What’s new this week?” Dr. Bilazarian highlights newly published literature on heart issues associated with COVID-19, especially in patients with troponin elevation and prior heart disease history. He discusses the risks of contamination and infection associated with COVID-19 for HCPs, equipment and facilities, as well as transport of critically ill patients. He notes that echo machines should be brought to patients, and with the very high risk of contamination during TEE, physicians should consider repeat TTE or alternatives.

Dr. Bilazarian then shows data from 1591 ICU patients in Lombardy, Italy from February 20 to March 18. Nearly 70% had at least one comorbidity, and nearly half had hypertension. 99% required respiratory support, 5 patients required ECMO, 9% of all positive cases required ICU care, and mortality in these ICU patients was 26%.

Next, he presents data that older patients with cardiovascular disease (CVD) have a lower incidence of disease with COVID-19, but higher severity, while younger patients without CVD have a higher incidence of disease, but lower severity. The data showed that this may be related to older patients with CVD having lower ACE2 levels and higher angiotensin II proinflammatory signaling while younger patients without CVD have higher ACE2 levels and lower angiotensin II signaling.

After touching on guidelines from professional societies around the world regarding patients taking RAAS blockers, and additional reports that proning patients can help avoid potential mechanical ventilation, Bilazarian highlights STEMI mimetics and the finding that physicians may not want to take patients to the cath lab if they don’t see reciprocal changes on another area of the patient’s ECG. He also shows results from a poll of interventional cardiologists that revealed evolving patterns of care for patients with confirmed or highly likely COVID-19 infection who present with STEMI or NSTEMI. In addition, he touches on the challenges of discriminating heart failure from COVID-19 infection, noting that while ground-glass opacity and thickening of interlobular septa are seen on chest CT in both conditions, the ratio of central and gradient distribution is higher in heart failure than COVID-19 and pulmonary vein enlargement, lesion distribution, and morphology are important distinguishing features on chest CT.

In this video, Dr. Bilazarian highlights a paper by Fried et al. published in Circulation on April 3, 2020 describing evolving treatment pathways in 4 different cardiovascular presentations of COVID-19 infection. His take-home message is that in patients presenting with what appears to be a typical cardiac syndrome—such as ST segment elevation, cardiogenic shock, decompensated heart failure, or a heart transplant—COVID-19 infection should be in the differential during the current pandemic, even in the absence of fever or cough.

Toward the end of the call, Dr. Bilazarian briefly reviews coagulopathy considerations in COVID-19, noting that the International Society on Thrombosis and Haemostasis (ISTH) recommends prophylactic treatment with low molecular weight heparin (LMWH) in all hospitalized COVID-19 patients. He also mentions protection strategies—FFP3 mask and facial shield, surgical gown, leg covers, and double gloves—used by a cath lab team supporting a COVID-19 positive patient with Impella® in Italy.

Toward the end of the call, Dr. Bilazarian highlights 2 new posts on the A-CURE website: a video from Dr. Federico Pappalardo on TEE guided Impella placement and an interview with Dr. Pappalardo about his experience in Milan. Dr. Dan Raess concludes this video with a brief mention of data from the IQ registry regarding 12 patients supported with Impella for COVID myocarditis.

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To learn more about the Impella® platform of heart pumps, including important risk and safety information associated with the use of the devices, please visit: abiomed.com/important-safety-information

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