Cardiac Implications of Novel Wuhan Coronavirus: ACC Guideline
The American College of Cardiology (ACC) has issued a guideline on cardiac implications of coronavirus. The clinical bulletin released on Feb 13, 2020, aims to address cardiac implications of the current epidemic of the novel coronavirus, now known as COVID-19.
COVID-19, first reported in late December 2019, originating in Wuhan, China has reportedly claimed the lives of more than 1,500 people as of Feb 14, 2020. COVID-19 is a betacoronavirus, like SARS and MERS, presenting as viral pneumonia with a wide range of acuity. It appears to have greater infectivity and a lower case fatality rate when compared to SARS and MERS.
99% of all cases of the deadly virus are in mainland China, where despite aggressive containment efforts, case counts continue to rise rapidly. According to the recent reports, there were 2,641 new confirmed infections across mainland China, bringing the national total to 66,492.
The bulletin, reviewed and approved by the college's Science and Quality Oversight Committee, "provides background on the epidemic, which was first reported in late December 2019, and looks at early cardiac implications from case reports," the ACC noted in a press release. "It also provides information on the potential cardiac implications from analog viral respiratory pandemics and offers early clinical guidance given current COVID-19 uncertainty."
Early cardiac implications from case reports on Wuhan Coronavirus
Early case reports suggest patients with underlying conditions are at higher risk for complications or mortality from COVID-19; up to 50% of hospitalized patients have a chronic medical illness. 40% of hospitalized patients with confirmed COVID-19 patients have cardiovascular or cerebrovascular disease.
In a recent case report on 138 hospitalized COVID-19 patients, they noted, 19.6% developed acute respiratory distress syndrome, 16.7% developed arrhythmia, 8.7% developed shock, 7.2% developed acute cardiac injury, and 3.6% developed acute kidney injury. "Rates of complication were universally higher for ICU patients," they wrote.
The first reported death was a 61-year-old male, with a long history of smoking, who succumbed to acute respiratory distress, heart failure, and cardiac arrest.
Given the current uncertainty about the virus, the bulletin provides the following clinical guidance:
- COVID-19 is spread through droplets and can live for substantial periods outside the body; containment and prevention using standard public health and personal strategies for preventing the spread of the communicable disease remains a priority.
- In geographies with active COVID-19 transmission (mainly China), it is reasonable to advise patients with underlying cardiovascular disease of the potential increased risk and to encourage additional, reasonable precautions.
- Older adults are less likely to present with fever, thus close assessment for other symptoms such as cough or shortness of breath is warranted.
- Some experts have suggested that the rigorous use of guideline-directed, plaque stabilizing agents could offer additional protection to CVD patients during a widespread outbreak (statins, beta blockers, ACE inhibitors, ASA)v; however, such therapies should be tailored to individual patients.
- It is important for patients with CVD to remain current with vaccinations, including the pneumococcal vaccine given the increased risk of secondary bacterial infection; it would also be prudent to receive influenza vaccination to prevent another source of fever which could be initially confused with coronavirus infection.
- It may be reasonable to triage COVID-19 patients according to the presence of underlying cardiovascular, respiratory, renal, and other chronic diseases for prioritized treatment.
- Providers are cautioned that classic symptoms and presentation of AMI may be overshadowed in the context of coronavirus, resulting in underdiagnosis.
- For CVD patients in geographies without widespread COVID-19 emphasis should remain on the threat from influenza, the importance of vaccination and frequent handwashing, and continued adherence to all guideline-directed therapy for underlying chronic conditions.
- COVID-19 is a fast-moving epidemic with an uncertain clinical profile; providers should be prepared for guidance to shift as more information becomes available.
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