NICE releases rapid guideline on acute myocardial injury in COVID-19

National Institute for Health and Care Excellence (NICE) has released new rapid guidelines for acute myocardial injury.

The purpose of this Guideline is to help healthcare professionals who are not cardiology specialists identify and treat acute myocardial injury and its cardiac complications in adults with known or suspected COVID-19 but without known pre-existing cardiovascular disease.

This guideline is for:

• health and care practitioners
• health and care staff involved in planning and delivering services
• commissioners

The guideline covers care in a hospital setting. The recommendations are specifically for acute myocardial injury associated with COVID-19 and should be used alongside good clinical practice.

The recommendations bring together:

• evidence from published literature on COVID-19 with acute myocardial injury
• existing national and international guidance and policies
• advice from specialists working in the NHS from across the UK. These include people with expertise and experience of treating patients with acute myocardial injury during the current COVID-19 pandemic.

NICE has developed these recommendations in direct response to the rapidly evolving situation and so could not follow the standard process for guidance development. The guideline has been developed using the interim process and methods for developing rapid guidelines on COVID-19, and includes a systematic literature search. The evidence tables for this search will be published alongside the guideline. The recommendations are based on evidence and expert opinion and have been verified as far as possible. We will review and update the recommendations as the knowledge base and expert experience develops.

1. Communicating with patients

• Communicate with patients, their families and carers, and support their mental wellbeing to help alleviate any anxiety they may have about COVID‑19. For patients with a newly diagnosed myocardial injury, signpost to charities (such as the British Heart Foundation, Pumping Marvellous Foundation, Arrhythmia Alliance, Atrial Fibrillation Association and Cardiomyopathy UK) and support groups (including NHS Volunteer Responders) and UK government guidance on the mental health and wellbeing aspects of COVID-19.
• Provide patients, their families and carers with information that meets their communication needs (see NHS England's Accessible Information Standard).

2 Minimising risk for patients and healthcare workers

• When patients with known or suspected COVID‑19 have been identified, follow appropriate UK government guidance on infection prevention and control. This includes recommendations on using personal protective equipment (PPE), patient transfers, and options for outpatient settings.
• If COVID‑19 is later diagnosed in a patient not isolated from admission or presentation, follow UK government guidance on management of exposed healthcare workers and patients in hospital settings.
• All healthcare workers involved in receiving, assessing and caring for patients who have known or suspected COVID‑19 should follow UK government guidance for infection prevention and control. This contains information on using PPE, including visual and quick guides for putting on and taking off PPE.

3 Diagnosing acute myocardial injury in patients with suspected or confirmed COVID-19

Diagnostic tests

• Be aware that acute myocardial injury and its complications:

• were observed in 9.5% of all patients dying in Italy with COVID-19 (up to 13 April 2020)
• display symptoms and signs similar to respiratory complications of COVID-19
  
• may develop at any stage of COVID-19.
  

• Be aware that acute myocardial injuries in patients with COVID-19 include:

• acute coronary syndromes
• arrhythmias
  
• cardiac arrest
  
• cardiogenic shock
  
• cardiomyopathy
  
• heart failure
  
• myocarditis
  
• pericarditis and pericardial effusion.
  

• Be aware that symptoms suggesting acute myocardial injury in patients with COVID-19 include:

• chest pain
• palpitation
  
• severe fatigue
  
• shortness of breath.
  

Diagnostic tests

• In patients with symptoms or signs that suggest acute myocardial injury, measure high sensitivity troponin I (hs-cTnI) or T (hs-cTnT) and NT-proBNP, and perform an ECG.

Use the following test results to help inform a diagnosis:

• evolving ECG changes suggesting myocardial ischaemia
• NT-proBNP level above 400 ng/litre
  
• high levels of high sensitivity troponin (hs-cTnI or hs-cTnT), particularly levels increasing over time.
  

• Be aware that elevated troponin levels may reflect cardiac inflammatory response to severe illness rather than acute coronary syndrome, and should be considered in the clinical context.

4 Managing myocardial injury in patients with suspected or confirmed COVID-19

• For all patients with a suspected or confirmed acute myocardial injury:

• monitor in a setting where cardiac or respiratory deterioration can be rapidly identified
• perform continuous ECG monitoring
  
• monitor blood pressure, heart rate and fluid balance.
  

• For patients with a clear diagnosis of a myocardial injury:

• seek specialist cardiology advice on treatment, further tests and imaging
• follow local treatment protocols.

• For patients with a high clinical suspicion of myocardial injury, but without a clear diagnosis:

• repeat high sensitivity troponin (hs-cTnI or hs-cTnT) and ECG daily, as dynamic change may help to monitor the course of the illness and establish a clear diagnosis
• seek specialist cardiology advice on further investigations such as transthoracic echocardiography and their frequency.

• Discuss the risks, benefits and possible likely outcomes of different treatment options with patients, families and carers using decision support tools (where available) so that they can make informed decisions about their treatment wherever possible.
• Be aware that treatments that may be used in COVID-19, such as azithromycin and hydroxychloroquine, may prolong the QTc interval and lead to arrhythmia. At the time of publication (22 April 2020), azithromycin and hydroxychloroquine can only be used to treat COVID-19 as part of nationally approved randomised controlled trials.
  
• Start all critical care treatment with a clear plan of how the treatment will address the diagnosis and lead to agreed treatment goals (outcomes). For recommendations on critical care treatment, see the NICE COVID-19 rapid guideline: critical care in adults.
  
• Review critical care treatment regularly and when the patient's clinical condition changes (see recommendations 4.1 and 4.2). Include in the review an assessment of whether the goals of treatment are clinically realistic.
  
• For support with decision making, see ethical guidance from the British Medical Association, the Royal College of Physicians and the General Medical Council.
• Stop critical care treatment when it is no longer considered able to achieve the desired overall goals (outcomes). Record the decision and the discussion with family and carers, the patient (if possible) or an independent mental capacity advocate (if appropriate).
  

For more details click on the link: www.nice.org.uk