Diagnosis and Management of CVD During COVID-19 Pandemic: ESC Guidance

Acknowledging the rapidly changing field, the ESC task force addressed part one with epidemiology, pathophysiology, & diagnosis and part two covering, care pathways, treatment, and follow-up. The two-part document provides practical information and advice to help clinicians diagnose and manage cardiovascular disease in patients with COVID-19

(1) Part one includes:

♦The impact of cardiovascular comorbidities on the epidemiology of COVID-19 noting that:

◊ Cardiovascular conditions are common in patients with COVID-19.

◊ The presence of cardiovascular disease is associated with severe COVID-19 and higher mortality.

◊ Cardiovascular risk factors are linked with severe COVID-19 and higher mortality.

♦Summary of the cardiovascular manifestations of COVID-19:

◊ Myocardial injury, arrhythmias, heart failure, vascular dysfunction, and thromboembolic disease are a consequence of severe infection.

◊ Long-term cardiovascular manifestations of COVID-19 are unclear, so careful follow-up is needed.

♦How to diagnose cardiovascular conditions in patients with the infection:

◊ Covering the clinical presentation (e.g. chest pain, breathlessness), electrocardiogram (ECG), relevant cardiac biomarkers, and imaging modalities (when to perform and how to do it safely).

(2)Part two includes:

♦Management and treatment pathways for common cardiovascular conditions such as:

◊ Diagnostic pathways and treatment algorithms for patients with suspected acute coronary syndromes.

◊ Diagnosis and management of patients with chronic coronary syndromes

◊ Advice on the management of patients with heart failure, valvular heart disease, arterial hypertension, acute pulmonary embolism, and arrhythmias.

◊ Follow-up via tele-health.

♦Treatment of SARS-CoV-2 Infection in patients with cardiovascular diseases including:

◊ Maintenance of cardiovascular medications.

◊ Drug-drug interactions, particularly regarding potential proarrhythmic properties.

♦Patient information such as:

◊ How to reduce the risk of transmission, maintain a healthy lifestyle, and manage cardiovascular disease.

Impact of cardiovascular comorbidities on COVID-19 outcomes

CV risk factors are linked with severe COVID-19 and higher mortality.

Cardiovascular manifestations and clinical course of COVID-19

COVID-19 has comparable cardiac manifestations to previous outbreaks of other coronaviruses.

Cardiac manifestations are associated with worse outcomes of COVID-19.

Long-term manifestations of COVID-19 are unclear, so extensive follow-up is needed.

Pathophysiology—mechanism of disease in relation to the cardiovascular system

The pathobiology of coronavirus infection involves SARS-CoV-2 binding to the host angiotensin-converting enzyme 2 (ACE2) receptor to mediate entry into cells. ACE2 is expressed in the lungs, heart and vessels.CVD associated with COVID-19 likely involves dysregulation of the ACE/ACE2 system due to SARS-CoV-2 infection and due to comorbidities, such as hypertension.

CVD comorbidity in COVID-19 may be either primary or secondary due to acute lung injury, leading to increased cardiac workload (particularly relevant in HF).

Other molecules such as neuropilin-1 can facilitate SARS-CoV-2 cell entry and infectivity, although significance of this process for CVD is unclear.

A cytokine storm, originating from an imbalance of T-cell activation with dysregulated release of interleukin (IL)-6, IL-17, and other cytokines, may contribute to CVD in COVID-19. IL-6 targeting is being tested therapeutically.

Immune system activation along with immunometabolism alterations may result in plaque instability, contributing to the development of acute coronary events.

Strategies for diagnosing SARS-CoV-2

Diagnosis of COVID-19 relies on a combination of epidemiological criteria (contact within incubation period), presence of clinical symptoms as well as laboratory testing [nucleic acid amplification tests (NAATs)] and clinical imaging-based tests.

Nucleic acid amplification tests are key diagnostic tests used worldwide.

Quality of sample collection (deep nasal swab) and transport (time) to laboratories are essential to avoid false-negative outcomes of nucleic acid testing.

Widespread testing proved efficient in the containment phase of the epidemic.

Testing should be performed as soon as possible in all symptomatic individuals and contacts of people testing positive to enable efficient isolation.

Anti-SARS-CoV-2 IgM and IgG antibody and SARS-CoV-2 antigen-based enzyme-linked immunosorbent assay tests are now widely used but require further development.

Rapid antigen tests can contribute to overall COVID-19 testing capacity but their sensitivity for is generally lower than for RT-PCR and can be performed best in cases with high viral load.

Lung computed tomography (CT) imaging may be used as a diagnostic test in COVID-19.

Diagnosis of cardiovascular conditions in COVID-19 patients

Clinical presentation

Chest pain

Chest pain and breathlessness are frequent symptoms in COVID-19.

Chronic and ACS presentations can be associated with respiratory symptoms.

Dyspnoea, cough, and respiratory distress

COVID-19 patients may present with cough, dyspnoea, and ARDS.

Cardiogenic shock

In COVID-19 patients with impaired end-organ perfusion at the risk of cardiogenic shock (CS) [e.g. large acute myocardial infarction (AMI)], sepsis or mixed shock should also be considered as a possible aetiology.

Myocarditis and hyperinflammatory syndrome should be considered as precipitating causes of CS.

Out-of-hospital cardiac arrest, pulseless electric activity, sudden cardiac death, tachyarrhythmias, and bradyarrhythmia

Growing evidence worldwide shows a major decrease in the diagnosis and management of cardiac arrhythmias during the current pandemic.

Symptoms of brady- and tachyarrhythmias do not differ from the usual clinical presentation; however, given the overlap with some of the COVID-19 clinical manifestations, both the general public and healthcare professional (HCP) should remain alert for signs and symptoms of cardiac arrhythmias.

There has been an increase in out-of-hospital cardiac arrest (OHCA) in correlation to the COVID-19 pandemic and a worsening in its short-term outcome.

In-hospital cardiac arrest in COVID-19 patients is mainly secondary to pulseless electrical activity (PEA) and/or asystole. Shockable rhythms are only present in a minority of cases.

The occurrence of arrhythmias in stable COVID-19 patients appears to be low. Conversely, arrhythmia incidence appears to be higher in critically ill patients and in patients with elevated markers of myocardial injury.

Hospitalization for pneumonia and time course of increased subsequent risk of cardiovascular death

Pneumonia, influenza, and SARS are associated with a markedly increased short-term risk for subsequent CV events.

Alertness for CV events, such as ACS, stroke, and venous thromboembolic events, in the short term after pneumonia and a careful risk management approach in individuals with pre-existing CVD is needed.

Non-invasive imaging

Do not perform routine cardiac imaging in patients with suspected or confirmed COVID-19.

COVID-19-positive and -negative patients should not cross in waiting area/scanner area, etc.

Prevent contamination from patients to other patients, to imagers and imaging equipment.

Perform imaging studies in patients with suspected or confirmed COVID-19 only if the management is likely to be impacted by the results.

Re-evaluate which imaging technique is best for your patients both in terms of diagnostic yield and infectious risk for the environment.

The imaging protocols should be kept as short as possible.

Transthoracic and transoesophageal echocardiography

Avoid performing transthoracic, transoesophageal and stress echocardiograms in patients in which test results are unlikely to change the management strategy.

Transoesophageal echocardiography (TOE) carries increased risks of spread of COVID-19 due to exposure of HCP to aerosolization of large viral load and should not be performed if an alternative imaging modality is available.

In COVID-19-infected patients, the echocardiogram should be performed focusing solely on the acquisition of images needed to answer the clinical question to reduce patient contact with the machine and the HCP performing the test.

Point of care focused ultrasound (POCUS), focused cardiac ultrasound study (FoCUS), and critical care echocardiography performed at bedside are effective options to screen for CV complications of COVID-19.

Computed tomography

Cardiovascular CT should be performed in hospitalized patients only with indications in which imaging results will likely impact management.

Coronary computed tomography angiography (CCTA) may be the preferred non-invasive imaging modality to diagnose CAD since it reduces the time of exposure of patients and personnel.

Cardiac CT may be preferred to TOE to rule out left atrial appendage and intracardiac thrombus prior to cardioversion.

In patients with respiratory distress, chest CT is recommended to evaluate imaging features typical of COVID-19.

Check renal function when contrast is indicated.

Cardiac magnetic resonance

Use shortened CMR protocols focused to address the clinical problem.Check renal function when contrast is indicated.

CMR is preferred in clinically suspected acute myocarditis.

The authors stressed that this comprehensive review was not a formal guideline but rather a document that provides a summary of current knowledge and guidance to practising clinicians managing patients with CVD and COVID-19.

They concluded, "The recommendations are mainly the result of observations and personal experience from healthcare providers. Therefore, the information provided here may be subject to change with increasing knowledge, evidence from prospective studies, and changes in the pandemic. Likewise, the guidance provided in the document should not interfere with recommendations provided by local and national healthcare authorities."

For further information:

1. European Society of Cardiology guidance for the diagnosis and management of cardiovascular disease during the COVID-19 pandemic: part 1—epidemiology, pathophysiology, and diagnosis. Eur Heart J. 2021. doi:10.1093/eurheartj/ehab696.
2. 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.