key: cord-1042385-uh9l11ny authors: Naghshtabrizi, Behshad; Bashirian, Saeed; Shirafkan, Naghmeh; Naghshtabrizi, Nima; Mehri, Fereshteh title: What Is Important in Patients with COVID-19 Associated with Myocardial Infarction? date: 2020-10-03 journal: J Tehran Heart Cent DOI: 10.18502/jthc.v15i4.5949 sha: 3339479800243ce244169145240d9b36494642ee doc_id: 1042385 cord_uid: uh9l11ny nan role played by ACE2 receptors as functional receptors for SARS-CoV-2 since they are highly expressed in myocardial and lung alveolar cells. 13 According to single-cell RNA sequencing via reverse transcription-polymerase chain reaction (RT-PCR), more than 7.5% of myocardial cells have positive ACE2 expression, which can provide a suitable site for the binding of the spike proteins of SARS-CoV-2. 2 This interaction between ACE2 receptors and spike proteins in myocardial cells can trigger a cytokine storm and ultimately lead to vascular inflammation, plaque instability, myocardial inflammation, and myocardial suppression. 13, 14 The second important issue is the controversy surrounding the therapeutic strategy for MI in patients infected with SARS-CoV-2. There is as yet no specific treatment protocol for the treatment of this infection, with various pharmacologic agents being under active investigation. Supportive treatment with remdesivir, ribavirin, lopinavir/ ritonavir, favipiravir, antimalarials (eg, chloroquine and hydroxychloroquine), azithromycin, corticosteroids, and biologics (eg, tocilizumab) has been administered to these patients. 10, 15 It is important to consider that the interactions between these drugs and other cardiovascular medications such as antihypertensives, antiarrhythmics, anticoagulants, antiplatelets, and statins could increase the side effects of the drugs, especially in patients with MI. 3 On the other hand, medications such as lopinavir/ritonavir can cause QT and PR-interval prolongation, which may be more hazardous in MI patients infected with SARS-CoV-2 since they have inherent electrical disturbances. 16, 17 Chloroquine and hydroxychloroquine affect the intracellular pH level, which leads to electrolyte abnormalities, cardiotoxicity, and prolonged QT intervals. 18 The administration of azithromycin in patients with heart disorders who are infected with SARS-CoV-2 could interfere with anticoagulants, statins, antiarrhythmics, and other QT-prolonging agents, which might lead to torsades de pointes. 16 The concurrent consumption of the aforementioned medications by MI patients with SARS-CoV-2 seems injudicious. It is, therefore, vital that new drugs be introduced into the current pharmacologic armamentarium for the management of this special group. Research has been conducted to find potent drugs with fewer side effects. Cavagna et al, 19 in a monocentric crosssectional study, used calcineurin-inhibitors in the treatment of SARS-CoV-2-infected cases with organ transplantation or rheumatic diseases. They posited that the use of calcineurin inhibitor-based immunosuppressive regimens such as tacrolimus could be considered a safe therapeutic option for SARS-CoV-2 because they are capable of suppressing the phosphatase activity of calcineurin and result in decreased interleukin-2 production. Another investigation suggested that cyclosporine, which is a commonly-used and well-tolerated drug approved by the FDA, be used as a treatment candidate in patients with MI on the strength of its cardioprotective positive effects. 20 Cyclosporine is presumed to confer cytoprotection by inhibiting the opening of the mitochondrial permeability transition pore (MPTP) and stabilizing the inner mitochondrial membrane by preventing cyclophilin D from binding to the adenine nucleotide translocator, which could be useful in patients with MI who are infected with SARS-CoV-2. 21 In conclusion, in this letter, as is depicted by the figure below, we have focused on 2 important issues: the possible risk of MI in patients who are infected with SARS-CoV-2 and the different therapeutic protocols that are currently applied for their management. We have also highlighted the need for the replacement of these protocols with safer ones given the risk they may pose to this group of patients. Calcineurin inhibitors and cyclosporine are more likely to have fewer cardiac side effects in MI patients infected with SARS-CoV-2. Indubitably, however, both calcineurin inhibitors and cyclosporine require extensive clinical trials for the further evaluation of their effects in such patients. Clinical course and outcomes of critically ill patients with SARS-CoV-2 pneumonia in Wuhan, China: a single-centered, retrospective, observational study Planning and provision of ECMO services for severe ARDS during the COVID-19 pandemic and other outbreaks of emerging infectious diseases Open COVID-19 Data Curation Group. 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