key: cord-0781844-48z5x8g4
authors: Chatzizisis, Yiannis S.; Gajanan, Ganesh; Bhatt, Deepak L.; Dangas, George; Porter, Thomas
title: Management of acute myocardial injury in patients with confirmed or suspected COVID-19
date: 2020-06-16
journal: Atherosclerosis
DOI: 10.1016/j.atherosclerosis.2020.06.008
sha: b2c61d4f67c30ee1d2d56ca436b3fa77926bbd01
doc_id: 781844
cord_uid: 48z5x8g4

nan

The Coronavirus Disease-2019 (COVID-19) pandemic has made the healthcare system rethink its approach to even the most basic practices. The same holds true for cardiovascular medicine, where protocols and quick decision making are required for time-sensitive and life-threatening clinical scenarios. At times like these, we are compelled to think outside the box and use alternate, easily accessible, safe and multidisciplinary approaches.

COVID-19 can affect the heart in multiple ways and recent reports indicate that acute myocardial injury and subsequent troponin and/or ST segment elevation are common findings and risk predictors among these patients. COVID-19 can induce oxygen demand or supply mismatch, plaque rupture, myocardial inflammation, and microvascular constriction or thrombosis, leading to coronary myocardial injury, i.e. type 1 or 2 myocardial infarction (MI), or non-coronary myocardial injury (MINOCA), i.e. myocarditis, stress-induced cardiomyopathy, and thrombotic microangiopathy (TMA). 1,2 A recent case series showed high prevalence of noncoronary myocardial injury in patients presenting with ST elevation. 3 Quick and effective triaging of confirmed/suspected COVID-19 patients is of utmost importance to maximize patient care, while minimizing the exposure of skilled personnel and equipment. Considering the above implications, we propose a comprehensive protocol to manage myocardial injury in suspected/confirmed infection ( Figure 1 ). The protocol incorporates the ACC/SCAI recommendations for management of acute coronary syndromes in COVID-19 patients, 1,2 but goes one step beyond, providing a global approach for the management of myocardial injury at the point of care where critical triaging and decision-making take place.

Both suspected and confirmed COVID-19 patients with acute myocardial injury are treated similarly. The cardiovascular team does the initial evaluation and triaging through teleconsult if possible. Triaging is based on a combination of history/risk factors, ECG pattern, cardiac biomarkers (levels and trend), focused perfusion (contrast) echocardiography (FPE), or coronary computed tomography angiography if available. FPE plays a central role in triaging as it provides critical information at bedside regarding the presence and distribution of wall motion abnormalities (WMA) and myocardial perfusion. It is quick, focuses on contrast-enhanced WMA and perfusion, and allows to better assess whether there is ongoing myocardial ischemia/injury. 4 Patients with definite or probable regional WMA in a coronary distribution are treated as MI, while those with WMA outside of a coronary artery distribution, are considered as non-coronary myocardial injury, i.e myocarditis, stress cardiomyopathy or TMA. WMA pattern and perfusion can further differentiate myocarditis (normal microvascular perfusion with a focal or global WMA) from TMA (WMA and perfusion confined to one/two segments) or stress cardiomyopathy (mid/apical WMA with/without perfusion abnormalities). For patients with MI, contrast-enhanced WMA combined with myocardial perfusion can assist in differentiation of type 1 (acute atherothrombosis resulting in reduced perfusion and WMA in a coronary territory) from type 2 (demand/supply mismatch with WMA in a coronary territory, but preserved or slightly reduced perfusion).

Type 2 MI (including coronary spasm) and stable non-ST elevation MI are treated conservatively, whereas unstable non-ST elevation MI follows an early invasive strategy, provided that the benefit from revascularization exceeds the risk of respiratory failure, adverse outcomes and COVID-19 exposure. For STEMI, the reperfusion approach is based on patient's clinical, electrical, and hemodynamic stability, bleeding risk, time delays, and severity of pneumonia. Even though primary percutaneous coronary intervention (PCI) remains the treatment of choice, some deviations can be considered. Stable lateral or inferior STEMI without right ventricular involvement can be considered for thrombolysis after carefully considering the bleeding risk and age in patients with critical illness/severe pneumonia or anticipated delays in percutaneous reperfusion. Rescue PCI can be considered if thrombolysis fails after considering the patient's respiratory status and prognosis. Anterior or unstable STEMI warrants primary PCI in the absence of severe acute lung injury. In anterior or unstable STEMI patients with critical illness or severe pneumonia, thrombolysis or even conservative therapy can be considered after balancing the bleeding risk, severity of lung injury, and reperfusion benefit. 1,2 Thrombolysis should be considered only in patients with high likelihood for STEMI, to avoid unnecessary, and potentially harmful, thrombolysis of non-coronary ST-elevation syndromes.

In conclusion, we believe that a comprehensive protocol-based triaging and decision making at the point of care in COVID-19 patients presenting with acute myocardial injury is warranted to limit provider anxiety and confusion, provide a pathway for streamlined management of these challenging patients, while simultaneously minimizing the exposure of medical personnel to this highly contagious virus. Institutions caring for COVID-19 patients would benefit from a heart team-like approach -developing a combined cardiology/critical care team that meets daily to optimize diagnostic and therapeutic strategies. Undoubtedly, the COVID-19 pandemic poses enormous pressure on health care systems worldwide, but at the same time it brings an opportunity to review and revisit patient care pathways to make them faster, smarter and more cost-effective. 5 

Chatzizisis has received speaker honoraria, advisory board fees and research grant from Boston Scientific and research support from Medtronic

Society of Cardiovascular Patient Care, TobeSoft; Chair: American Heart Association Quality Oversight Committee; Data Monitoring Committees: Baim Institute for Clinical Research (formerly Harvard Clinical Research Institute, for the PORTICO trial

Baim Institute for Clinical Research (formerly Harvard Clinical Research Institute; RE-DUAL PCI clinical trial steering committee funded by Boehringer Ingelheim; AEGIS-II executive committee funded by CSL Behring)

Slack Publications (Chief Medical Editor, Cardiology Today's Intervention), Society of Cardiovascular Patient Care (Secretary/Treasurer), WebMD (CME steering committees); Other: Clinical Cardiology (Deputy Editor), NCDR-ACTION Registry Steering Committee (Chair), VA CART Research and Publications Committee (Chair)

Svelte; Trustee: American College of Cardiology; Unfunded Research: FlowCo, Merck, Novo Nordisk, Takeda; Thomas Porter is a consultant for Lantheus Medical, and a speaker for Bracco Diagnostics. He has equipment support from Philips Healthcare

Considerations for cardiac catheterization laboratory procedures during the COVID-19 pandemic

Catheterization laboratory considerations during the COVID-19 pandemic: From ACC's Interventional Council and SCAI

ST-Segment Elevation in Patients with Covid-19 -A Case Series

Clinical applications of ultrasonic enhancing agents in echocardiography

COVID-19: An Unintended Force for Medical Revolution?

We would like to thank the following collaborators for their advice on the invaluable development of this protocol: