Brown CR, Chen Z, Khurshan F, Groeneveld PW, Desai ND. JAMA Cardiol. doi:10.1001/jamacardio.2020.1445 Published online June 17, 2020.
- Background: Opioids prescribing for pain management have contributed to long term issues related to opioid use.
- Objective: To assess the frequency and discharge dose factors following cardiac surgery of persistent opioid use in prior opioid nonusers (No opioid RX within 180 days of Cardiac Surgery).
- Retrospective cohort study using a national administrative claims data base 1/1/2004 to 12/31/2016
- Results: (90-180 days post-surgery)
- Eligible Heart Surgery Patients – 35,817
- Coronary Bypass Surgery (CABG) – 25,673 (71.7%)
- Valve Surgery – 10,144 (28.3%)
- Post Heart Surgery opioid users:
- CABG – 2609 (10.2).
- Valve surgery – 821 (8.1%). (CABG vs. Valve surgery, P<0.001)
- Risk factors for persistent opioid use:
- Demographics – CABG surgery, Women, Younger patients
- Pre-surgery Factors – CHF, Chronic Lung disease, Diabetes, Kidney Failure, Chronic Pain, and Alcoholism, pre op use of benzodiazepines and muscle relaxers.
- Opioid Dosing: Discharge Rx > 300 mg Oral Morphine Equivalents
- The database is private insure of managed Medicare and may not be representative of all populations.
- Such databases are subject to coding errors and do not represent other sources of narcotics
- Approximately 1 in 10 patients post cardiac surgery continue to use opioids > 90 days post-surgery.
- Higher opioid discharge doses were associated with greater late use.
- Editorial Comment:
- Screening patient’s pre-op for opioid risk is important and in patients with both percutaneous as well as surgical revascularization options, opioid use risk may be a useful not usually discussed factor in decision-making.
George W. Vetrovec, MD, MACC, MSCAI
Effect of Colchicine vs Standard Care on Cardiac and Inflammatory Biomarkers and Clinical Outcomes in Patients Hospitalized With Coronavirus Disease 2019 The GRECCO-19 Randomized Clinical Trial
Deftereos SG, Giannopoulos G, MD, Vrachatis DA, et. al. on behalf of the GRECCO-19 investigators. JAMA Network Open. 2020;3(6):e2013136. doi:10.1001/jamanetworkopen.2020.13136
GRECCO-19 (Greek Study in the Effects of Colchicine in COVID-19 Complications Prevention) is a randomized study involving 16 tertiary care centers in Greece who randomized 105 patients to standard medical care vs. colchicine treatment in the setting of COVID – 19 care.
- Study Goal: To assess the potential benefit of colchicine treatment to reduce cardiac inflammatory biomarkers and clinical outcomes in hospitalized patients with COVID – 19.
- Colchicine Dosing: Loading – colchicine 1.5 mg followed by 0.5 mg at 1 hour. Maintenance dose – 0.5 mg twice daily. Dose duration: Up to 3 weeks.
- Population: Patients – 105; Male – 60 (58.1%); Median Age – 64 (range 54-76); Control Patients – 50 (47.6%), Colchicine Group – 55 (52.4%). [All median ranges expressed as interquartile ranges]
- Biomarker Results:
- Median maximum high-sensitivity troponin levels: Control patients – 0.0112 (0.0043-0.0193); Colchicine Group – 0.008 (0.004-0.0135) P=0.34 [Values expressed as ng/ml]
- Median maximum C-reactive protein levels: Control patients – 4.5 (1.4-8.9);
- Colchicine Group – 3.1 (0.8-9.8) P=0.73 [Values expressed as mg/dl].
- Clinical Results:
- Time to deterioration by 2 points on a 7-grade clinical status scale, ranging from able to resume normal activities to death: Control Group – 7/50 (14%); Colchicine Group – 1/55 (1.8%) [Odds ratio 0.11; 95% CI, 0.01-0.96; P=0.02]
- Mean (SD) event Free Survival: Control Group – 18.6 days (0.83) days; Colchicine Group – 20.7 (0.31) [log rank P=0.03]
- D-dimer (Not a prespecified study value): Control Group – 0.92 (0.68 – 2.77); Colchicine Group – (0.76 (0.41 – 1.59) μg/mL [P = .04].
- Adverse Events: There were no significant differences between groups except for more frequent diarrhea in the Colchicine Group
- Limitations: No control of other medications or management with patients enrolled in variable additional drug therapy trials including azithromycin and hydroxychloroquine as well as other drugs. Likewise, there were variations in anticoagulation strategies.
- Colchicine provided a clinical benefit in a small patient population without a prospective biomarker benefit; However, a retrospective evaluation showed significantly lower levels D-dimer levels for colchicine patients suggesting a potential anti-inflammatory effect on an recognized COVID – 19, high risk biomarker.
- These results should be considered hypothesis generating.
Characteristics Associated With Out-of-Hospital Cardiac Arrests and Resuscitations During the Novel Coronavirus Disease 2019 Pandemic in New York City
Lai PH, Lancet EA, Weiden MD, et. al. JAMA Cardiol. doi:10.1001/jamacardio.2020.2488
- Out of Hospital cardiac arrests (OHCA) have increased during the COVID – 19 Pandemic.
- In New York City the incidence of OHCA was increased to 10X that of 2019 at the peak.
- To assess factors associated with OHCA during the COVID – 19 period.
- Study period – March 1 – April 25, 2019 (baseline) compared with the same dates in 2020 (COVID – 19 Period).
- Study populations: Baseline period – 1336; COVID – 19 Period -3989.
- Incidence of OHCA Baseline was 15.9/100,000 population; COVID – 19 47.5/100,000 population; 3 times greater in the COVID – 19 Period.
- Demographics: Patients during the COVID – 19 period tended to be older 72 vs. 68 years and more likely African American 34.2 vs. 20.4% and Hispanic 25.5 vs. 20.6% while the number of whites declined from 34.3% to 20.4%.
- Comorbidities: Patients during the COVID – 19 Period were more likely hypertensive (53.5 vs. 45.7%); Diabetic (35.7 vs. 26.0%) and more likely to have physical limitations (56.6 vs. 47.5%). In contrast, the incidence of cardiac disease, asthma/COPD, cancer and CVAs were not differenct between the two periods.
- OHCA presentations: During COVID – 19 Period, patients were significantly more likely to have pulseless electrical activity or asystole.
- Outcomes: During the COVID – 19 Period return of spontaneous circulation (ROSC) was reduced 18.2 vs. 34.7% (p<0.001) while sustained ROSC was achieved in only 10.2 vs. 25.2% (p<0.001) of patients in the COVID – 19 Period, with significantly more frequent discontinuance of resuscitation in the field because of failure to attain ROSC despite no difference in bystander CPR, time to resuscitation, or total resuscitation time between the two periods.
- The authors conclude that vulnerable populations need to be identified early and intensely managed in the outpatient setting to minimize risk of OHCA during the COVID – 19 Pandemic.
George W. Vetrovec, MD, MACC. American College of Cardiology – ACC.org Interventional Cardiology
As of Mid-June 2020
- Nearly one-third of catheterization laboratories have resumed normal reentry of cases.
- The greatest barrier to reentry is patients’ concern about the risk of COVID- 19 exposure which remains an important educational challenge.
- Operators tend to perform complete revascularization (avoiding staging) to minimize hospital days and admissions.
- Laboratories tend to match physician skills and experience to speci!c cases to optimize results and avoid complications.
- These results suggest a significant improvement in CV re-opening of cardiac catheterization services emphasizing efficiency of operations such as optimal operator selection for each case and most importantly, emphasis on single procedure revascularization without staging.
Prevalence of COVID-19 in Out-of-Hospital Cardiac Arrest: Implications for Bystander CPR.
Circulation: 10.1161/CIRCULATIONAHA.120.048951 Sayre MR, Barnard LM, Counts CR, et. al.
- The AHA has previously provided modified recommendations for CPR for out of hospital cardiac arrest (OHCA) in the face of the COVID – 19 Pandemic previously posted on the ACURE site.
- No data has been available to assess the actual risk of CPR for OHCA until this publication.
- The current study comprises OHCA with emergency medical services (EMS) involvement in Seattle and King County, WA from 1/1/2020 – 4/15/2020.
- Study Goal: To estimate the incidence of COVID-19 infection among a cohort of OHCA.
- EMS responded to 1.067 OHCAs from 1/12020 to 4/15/2020; EMS treated 478 (44.8%). COVID was lab test positive in 23 (2.2%) or considered high likelihood of COVID – 19 illness based on chart review in 13 (1.2%) episodes of OHCA.
- Focusing on the active COVID – 19 period, 2/26/2020 – 4/15/2020, EMS responded to 537 (50.3%) episodes of OHCA; EMS treated 230 (48.1) of this group.
- COVID – 19 was diagnosed by Test or likely clinical history in 3.7% of DOA and 6.5% of EMS treated cases.
- Distribution of COVID – 19, OHCA cases by site included 5% in homes, 11% in nursing homes and none in public places. Bystander CPR was performed in 57% of OHCA episodes.
- Risk of COVID – 19 infection to healthcare workers without PPE: 121 exposed – <5% had symptomatic infection from intensive care of a COVID – 19 patient.
- Risk of COVID infection for bystander’s is likely low as time of resuscitation is usually limited and chest compressions alone is thought to have a low probability of aerosolization of the virus from an infected patient.
- Local mortality was 15 per 100,000 for COVID (high for this area); COVID was present in <10% of OHCA. Considering a transmission risk of 10% for bystander, hands-only CPR without PPE, treating 100 OHCAs could lead to one COVID – 19 infection. With approximately a 1% mortality for COVID patients, a rescuer might die for every 10,000 patients treated. In contrast bystander CPR is likely to save 300 patients for every 10,000 treated.
- The authors state that given these numbers, current CPR guidelines for bystander CPR without PPE is justified unless a patient with OHCA has a high probability of infection, in which case delaying CPR to allow donning PPE is justified.
Telemedicine Outpatient Cardiovascular Care during the COVID-19 Pandemic: Bridging or Opening the Digital Divide?
Eberly LA, Khatana SAM, Nathan AS, et. al. Circulation: 10.1161/CIRCULATIONAHA.120.048185
- The use of digital/telephone systems for patient management has increased significantly during the COVID crisis.
- The likelihood is that utilization of telephone and telemedicine (video) remote medical evaluation will continue going forward.
- A above referenced manuscript addresses the population variations and acceptance and effective utilization of telephone and telemedicine based on social and personal characteristics.
- This emphasizes that to be effective, specific factors needed to be considered in achieving optimal communication methods despite the increased flexibility of telemedicine.
- While, telemedicine removes many barriers regarding travel, cost of transportation and parking for frail or otherwise patients with restrictive access, patients may have similar or different challenges to telemedicine (with video) as well.
- Patients with potential challenges to particularly video based medical visits include, older patients (limits to understanding or using technology) poorer patients (poor access to required equipment and broadband) and non-English speaking patients with general communication limits exacerbated by technology.
- This is a single, large center (University of Pennsylvania) evaluation of patients scheduled for a telemedicine visit, comparing factors involved in successfully completed visits vs. non-completed visits including a comparison of telephone vs. video encounters.
- Analyzed visits were assessed between March 16 – April 17, 2020 during the height of restricted visits.
- There were 2940 scheduled visits during this time of which 1,339 (46%) were completed and 1,601 (54%) were canceled/no-show visits.
- Numerically small but significant differences for those completing a telemedicine visit included patient age (mean 63 vs. 63, p<0.0001), being male (51% vs, 44%, p<0.0001) and English speaking (99% vs. 98%, p=0.03).
- There were no differences based on race/ethnicity, insurance/payor status or zip-come linked household income.
- were no differences based on race/ethnicity (p=0.25), insurance/payor class (p=0.12), or zip-code linked household income (p=0.38).
- Comparing telemedicine (video) vs. telephone-only visit completion, patients completing video visits were greater for males) 50% vs. 42%, p=0.01) but less likely to be black (24% vs. 34%, p<0.01) but likely to have a higher income.
- In terms of independent associations, non-English language was associated with a >50% lower telemedicine use, along with a lower use for females and a lower use for yearly incomes less than $50,000.
- While explanations for some of these observations such as lower use by females will require more in-depth study and the potential for expanded broadband and other digital enhancements including increased use of translation services are likely to occur, for the present, being aware of specific patient circumstances effecting patient acceptance and use of telephone and video medical services is critical for success.
Impact of the COVID-19 Pandemic on Emergency Department Visits — United States, January 1, 2019–May 30, 2020
Centers For Disease Control and Prevention
Morbidity and Mortality Weekly Report
Impact of the COVID-19 Pandemic on Emergency Department Visits — United States, January 1, 2019–May 30, 2020
Hartnett KP, Kite-Powell A, DeVies J, Coletta MA, Boehmer TK, Adjemian J, Gundlapalli AV, National Syndromic Surveillance Program Community of Practice Morbidity and Mortality Weekly Report Early Release / Vol. 69 June 3, 2020.
- Early in the COVID – 19 Pandemic, California in the USA along with Hong Kong, Autria and Italy noted significant drops in Emergency Department (ED) visits.
- To assess the impact of COVID – 19 on US ED visits the CDC compared ED visits in the early Pandemic period in the USA for 4 weeks (March 29-April 25, 2020) to the comparable time period in 2019 (March 31-April 27).
- ED visits were 42% less for the 2020-time frame compared to 2019 (Figure 1).
- The largest decreases were for children under age 14, females and geographically in the Northeast (Figure 2).
- It is difficult to directly assess the impact on cardiac events but the weekly mean visits for non-specific chest pain declined nationally by 24,258 visits, while weekly ED visits for cardiac arrest and ventricular fibrillation increased by 472, the most extreme ED visit adverse consequence that could be defined.
- The CDC emphasizes that telemedicine screening is ideal for many lower risk conditions but emphasizes the importance of continually educating patients on the importance of seeking immediate ED evaluation for potentially cardiac events.
- Health Care Providers and Hospitals are important sources of such information as has been reported here previously via the SCAI Every Second Still Counts information site and a joint Op Ed piece by the ACC and SCAI emphasizing this point.
The Spectrum of Cardiac Manifestations in Coronavirus Disease 2019 (COVID-19) – a Systematic Echocardiographic Study.
- Cardiac complications of COVID – 19 have been described on the basis of elevated troponin and clinical findings.
- No detailed evaluation of cardiac function by echocardiography has been described to identify the specific functional impairments that occur in patients with COVID – 19 hospital admission.
- To identify the frequency and types of echocardiographic findings in patients with COVID – 19 infection.
- Consecutive echocardiograms were performed within 24 hrs. on admission for 100 adult pts admitted with COVID – 19 diagnosed by assay positive respiratory samples for SARS-CoV-2 virus.
- Echocardiograms were repeated for patients with clinical deterioration defined as death, respiratory, hemodynamic or cardiac deterioration.
- Symptoms on admission were most commonly respiratory followed by fever, chest pain and fatigue.
- Seventy-two percent of pts had comorbidities: In order of frequency – Hypertension, diabetes, obesity and coronary artery disease.
- Lab markers of disease were: Troponin I (20%), CRP (87%), BNP (30%) and D-dimer (58%).
- Baseline echo cardiac parameters
- Normal LVEF – 90% of pts
- Normal LV filling pressures – 80%
- RV dilatation – 39%
- Baseline echo was normal in 32% of patients.
- In (20%) pts with clinical deterioration
- RV dilatation and dysfunction were present in 12/20 (60%) pts.
- DVT present in 5/12 (42%) of pts with RV failure
- LV dysfunction – 5 pts.
- Baseline Echo normal in 1/3.
- LVEF is not usually impaired.
- LV dysfunction present in 10% patients
- Clinical deterioration seen in 20% of patients.
- Clinical deterioration most commonly associated with reduced right heart function in which case an echo can be important for patient management.
- The authors recommend echocardiograms only for deteriorating conditions, not as a routine, but this recommendation is directed at staff protection and the concern about cleaning equipment between cases for overall patient and staff safety.
- This study again emphasizes the importance of assessing heart function by echocardiography and the significance of RV dysfunction in the cardiac deterioration of severe COVID – 19 disease.
Outcomes of Impella-supported high-risk nonemergent percutaneous coronary intervention in a large single-center registry
Azzalini L, MD, Johal GS, Baber U, Bander J, Moreno PR, Barman N, Kini AS, Bazi L, Kapur V, Sharma SK. Catheter Cardiovasc Interv. 2020;1–8.
- This report focuses on the early and one-year results of high-risk, non-urgent percutaneous coronary intervention (PCI) supported by Impella.
- The authors state the goal is to provide additional understanding for an Impella support concept for high-risk PCI.
- Study population includes all patients between 2009 and 2018 at The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York undergoing high-risk, non-emergent PCI supported by Impella 2.5 or CP.
- A propensity matched group of 250 patients having PCI with no hemodynamic was compared to the 250 patients in the Impella support group.
- Both groups had similar clinical and angiographic characteristics
- Procedural characteristics for the Impella supported group tended to be more complex with significantly more frequent Left Main PCI (26% vs. 11%, p < 0.001) with a trend toward more frequent rotational atherectomy in the PCI group (44% vs. 37%, P = 0.10) and a higher number of treated vessels (1.8 vs. 1.3, p < 0.001).
- Despite higher acute adverse events for the Impella group (peri-procedure MI, and major bleeding), the one-year results were equivalent for the two groups (MACE for Impella – 31.2% vs. Control – 27.4%, p = .78).
- These results provide important reassurance that Impella hemodynamic support provides a substrate for effective late results despite more complex disease in non-emergent, high-risk PCI.
Thromboelastographic Results and Hypercoagulability Syndrome in Patients With Coronavirus Disease 2019 Who Are Critically Ill
Background:Severe and apparently frequent coagulopathies occur in association with COVID – 19 infection including disseminated intravascular coagulopathy.Mechanisms related to this disorder are incompletely understood.
- This report covers all patients (pts) admitted to the Baylor St. Luke’s Medical Center in Houston March 15-April 9, 2020 with COVID – 19 infection.
- Standard deep venous thrombosis chemoprophylaxis was administered to all ICU admissions.
- Heparin infusion or enoxaparin treatment was administered to all patients with thrombotic complications.
- The definition of hypercoagulability was fibrinogen activity > 730 angle or maximum amplitude (MA) > 65 mm with heparinase correction
- Patients studied – 21; Mean age 68, range 50-89 yrs. 57% male.
- Comorbidities occurred in 20/21 (95%) pts ranging from 1-7 with a mean of 3.
- Thromboembolism risk factors included atrial fibrillation, malignant tumors or chronic kidney disease in 4 (19%) pts; ECMO was used in 4 (19%) pts, while 18 (85%) pts were treated with renal replacement therapy.
- Two (10%) pts died of pulseless electrical activity after development of acute pulmonary hypertension.
- Cohort mean INR, PTT and platelets were in normal ranges.
- Mean Fibrinogen and D-Dimer levels were elevated for the cohort.
- TEG results hypercoagulable in 19 (90%) of pts.
- Thrombotic events occurred in 13 (62%) of patients including 42 events, ranging from 1-8 per patient including arterial, central venous and or dialysis catheter or filter thrombosis.
- INR, PTT and platelet counts were not different between 10 pts with > thrombotic events compared to pts with <2 thrombotic episodes.
- Conversely, TEG MA for high event rate pts was significantly greater compared to the low event rate pts. Mean 75 vs. 61 mm. P=0.01.
- Overall TEG MA was 100% sensitive with a 100% negative predictive value.
- Despite thrombosis prophylaxis there was a high incidence of thrombotic complications not predicted by INR, PTT or platelet count.
- The D-Dimer and TEG results suggest complex inflammatory and coagulopathy mechanisms in COVID pts.
- The thrombotic risk of COVID – 19 may be often underdiagnosed or treated.
- Some institutions have gone to full anticoagulation of all high-risk ICU pts, but this puts all patients at increased bleeding complications.
- TEG may provide a method to effectively identify patients at high-risk and allow targeted systemic anticoagulation to minimize the risk of thromboembolic events.
Mortus JR, Manek SE, Brubaker LS, et. al. Key Points: Thromboelastographic Results and Hypercoagulability Syndrome in Patients With Coronavirus Disease 2019 Who Are Critically Ill. JAMA Network Open. 2020;3(6):e2011192. doi:10.1001/jamanetworkopen.2020.11192VIEW
- Stent Thrombosis has become an infrequent complication in recent years given improved stents, polymers and antiplatelet options.
- The authors note an increased potential risk of stent thrombosis based on the COVID – 19 inflammatory induced hypercoagulable state.
The authors report 4 cases to support their concerns for an increased risk of stent thrombosis.
- Case 1 is a 49-y. o. male with a 6-hour delayed presentation of a lateral wall STEMI treated with 2 overlapping DES stents. Thirty minutes later patient had recurrent symptoms with In stent thrombosis (ISR) potentially related to modest proximal stent underinflation and/or a minor distal stent edge dissection. The patient was treated with IC tirofiban and proximal stent overexpansion. He has continued on dual antiplatelet therapy with aspirin and ticagrelor. The patient had a cough and follow up serology was positive for COVID – 19 Infection.
- COVID infected patients comprising cases 2-4 all represent very late ST with myocardial infarction. Elderly age (71-86) was a consistent risk factor. All patients had guideline appropriate antiplatelet treatment but were on agents to treat Coronavirus that might interfere with the CYP3A4 metabolism of antiplatelet treatment.
- Given less frequent PCI during the COVID – 19 period, the incidence of ST in this center has been 13% compared to 1.2% the year before. Thus, a registry has been initiated in Spain to assess the relationship between ST and COVID infection.
- All 4 patients showed D-dimer elevations, as well as significant elevations in CRP, high sensitivity peak troponin as well as peak CK values, consistent with an inflammatory and prothrombotic state.
- The authors note that decisions unproven anti-viral regimens for COVID – 19 patients with prior stents might favor greater emphasis on the importance of antiplatelet therapy and/or use prasugrel (provided no contraindication of age > 75, prior stroke or weight < 60kg.) as the acute antiplatelet agent.
- This is an interesting report. If confirmed it potentially emphasizes the previously unrecognized risk of late stent thrombosis in the setting of the intense coagulopathy associated with COVID – 19.
Prieto-Lobato A, Ramos-Martínez R, Vallejo-Calcerrada N, Corbí-Pascual M, Córdoba-Soriano JG, A Case Series of Stent Thrombosis During the COVID-19 Pandemic, JACC Case Reports (2020), doi: https://doi.org/10.1016/j.jaccas.2020.05.024.VIEW
The SCAI has created patient education campaigns over the years, responding to contemporary public educational issues at critical times, particularly focusing on the signs of heart attack and stroke.
Given the current, well documented patient concerns leading to a 40 + % decline in acute myocardial infarction presentations with still to be fully documented consequences of survival and late heart failure the SCAI has launched a current fact sheet for patients with guidance for practitioners to reassure patients of the safety and importance of seeking scheduled and urgent medical events.
- Results of an SCAI survey shows significant population concern about the risk of going to the hospital in the setting of corona virus.
- The SCAI Seconds Still Count survey from a national sample of 1,068 persons over age 30 with a 95% confidence level and a margin of error +
- Survey results show the following COVOD – 19 concerns:
- Going to the hospital is riskier – 36%, than a hair salon – 27% or going to the beach – 16%.
- 61% of respondents believed that going to the hospital will likely result in a COVID – 19 infection.
- “Half of respondents are more afraid of contracting COVID – 19 than experiencing a heart attack or stroke” including 52% of persons over age 60 being more afraid of contracting COVID than a heart attack – 23% or a stroke – 25%.
- In response, the SCAI has developed a fact sheet for patients and a summary of hospital safety and patient guidelines in an attempt to reduce patient risk associated with failure to seek prompt medical attention.
- The SCAI on-line and print information is an excellent resource for patients and doctors to educate.
- The patient fear is not unexpected – an unintended consequence of shelter in place orders attempting to limit the spread of Coronavirus.
FDA Grants Emergency Use Authorization for Impella RP Right Heart Support in COVID – 19 Related Right Heart Decompensation Including Acute Pulmonary Edema
- Impella RP is FDA PMA approved for right ventricular support in acute right heart failure (RHF) associated with left ventricular assist implantation, post heart transplant, early RHF and acute myocardial infarction.
- Case reports have demonstrated the benefit of RP Impella for acute RHF secondary to pulmonary embolus (PE).
- Edler et. al. (1) describe 5 patients with acute PE and secondary right heart (RHF) and cardiogenic shock supported by Impella RP. All patients demonstrated a rapid hemodynamic recovery and were discharged alive.
- COVID – 19 Corona infection, while primarily a respiratory disease, is associated with a high incidence of other morbid conditions including a greater than 20% risk of cardiovascular events.
- Hypercoagulapathy is a frequent COVID – 19 risk and is often associated with in-situ and thromboembolic pulmonary embolus.
- As a consequence of respiratory failure and pulmonary emboli, right heart strain and failure is a common finding in COVID – 19 patients.
- Amir Kaki, associate professor of medicine at Wayne State School of Medicine reported on line a remarkable “save” using RP Impella in a COVID – 19 patient that had acute cardiac collapse from a pulmonary embolus.
- Kaki stated: “Impella RP is a powerful and effective therapy for RV shock in patients with massive PE”.
- Based on the risk of RVF and PE in COVID – 19, the FDA issued an
- Emergency Use Authorization letter supporting RP use in COVID -19 patients:
- FDA PMA Indication: The Impella RP System is indicated for providing temporary right ventricular support for up to 14 days in patients with a body surface area ≥1.5 m, who develop acute right heart failure or decompensation following left ventricular assist device implantation, myocardial infarction, heart transplant, or open-heart surgery.
Emergency Use Authorization: The Impella RP System is authorized to be used by healthcare providers (HCP) in the hospital setting for providing temporary right ventricular support for up to 14 days in critical care patients with a body surface area ≥1.5 m, for the treatment of acute right heart failure or decompensation caused by complications related to Coronavirus Disease 2019VIEW
Lemor A, Basir MB, Patel K, et. al. on behalf of the National Cardiogenic Shock Initiative Investigators. J Am Coll Cardiol Intv 2020;13:1171–8
Potential advantages of complete revascularization vs. culprit only PCI in the setting of cardiogenic shock remains controversial in the US. To address this question, data from the National Cardiogenic Shock Initiative (NCSI), a multicenter registry of patients undergoing early MCS (Impella) in the setting of acute myocardial infarction with cardiogenic shock (AMICS). The key features of the suggested protocol include Impella unloading prior to PCI revascularization of the culprit lesion focusing on invasive hemodynamic management. This review encompasses patients with multivessel disease who underwent culprit only or multivessel PCI at the index procedure based on operator decision.
- The retrospective analysis included 198 patients with multivessel (MV) coronary artery disease (CAD).
- 126 (64%) had MV PCI; 72 (36%) had culprit only PCI.
- Baseline characteristics of both groups were similar including age, sex, diabetes, prior PCI or CABG.
- Patients undergoing MV PCI had a non-significant trend to worse cardiac output and lactate levels up to 12 hours.
- By 24 hours post PCI, there were similar hemodynamic responses.
- Survival rates were similar; MV-PCI (69.8%) while culprit PCI 65.3%, p = 0.51.
- Acute kidney injury was not significantly different – MV-PCI 29.9% vs. culprit only PCI 34.2%; p = 0.64.
- Similar outcomes for patients undergoing MV- PCI suggests that in selected patients, MC PCI in patients with early unloading is an acceptable approach.
A COVID -19 Perspective
- Given the need to minimize ICU beds in the event of a COVID – 19 escalation and to minimize patient (and Staff) risk, minimizing hospital days is favorable.
- Thus, in appropriate AMICS patients, use of an NCSI type protocol with MV-PCI, hospitalization ideally can be reduced with a 70% expected survival.
George W. Vetrovec, MD, MACC. Poll Results: COVID-19 Hypercoagulable Complications – American College of Cardiology
Lax SF, Skok K, Zechner P, et al. Pulmonary Arterial Thrombosis in COVID-19 With Fatal Outcome: Results From a Prospective, Single- Center, Clinicopathologic Case Series. Ann Intern Med 2020;May 14:[Epub ahead of print].
Paranjpe I, Fuster V, Lala A, et al. Association of Treatment Dose Anticoagulation With In-Hospital Survival Among Hospitalized Patients With COVID-19. J Am Coll Cardiol 2020;May 5:[Epub ahead of print].
Background: In a recent Poll on ACC.org. the questions related to coagulation abnormalities in COVID – 19 patients. As noted, most respondents use anticoagulation in COVID – 19 patients. In order of risk pulmonary emboli was the highest including both in-situ and traditional embolic events.
- Baseline coagulation profiles are often abnormal.
- Thrombotic events appear common
- Pulmonary emboli appear most common.
- Prophylactic anticoagulants may reduce the risk of thrombotic events.
- Paranjpe et al. reported significantly reduced mortality for ventilated patients with COVID-19 on anticoagulants (29.1%) versus 62.7% for those not receiving anticoagulation.
- Individualized decisions are important to minimize bleeding complications
SCAI Position Statement on Optimal Percutaneous Coronary Interventional Therapy for Complex Coronary Artery Disease
Riley RF, et. al. for the Writing Group. Catheter Cardiovasc Interv. Published online. doi: 10.1002/ccd.28994.
This document is meant to discuss the approach to the high-risk PCI procedure defined by anatomic and patient features. The document is extensive and thus this commentary seeks to increase the awareness of some of the benefits and procedure related requirements within this topic which warrant consideration in the framework of achieving optimal PCI outcomes.
- Pre-Procedural Assessment:
- Coronary Anatomic Complexity – May require advanced techniques
- Higher-risk clinical features
- Emphasis on importance on multivessel disease
- Procedure risk
- Recognize high risk of surgical turndowns
- Reduced left ventricular (LV) function
- Acute Coronary Syndrome – Left Main (LM) and Low LVEF
- Emphasized the importance of mechanical Support (MCS)
- Most common is pVAD type of axial pump
- MCS support shown to increase frequency of complete revascularization
- Selected cases MCS supports improved LV function
- Managing the risk of acute kidney injury
- Concomitant valve disease
- Treatment of complex coronary artery disease
- Arterial access
- Anticoagulation and antiplanet treatment
- Intracoronary physiologic testing and imaging
- Special lesion considerations – LM, Bifurcations, Vein Grafts, In-stent Restenosis and Chronic Total Occlusions.
- The authors conclude: “…this SCAI consensus document provides an initial platform to offer guidance for achieving excellent outcomes for complex PCI and to support future investigations of this growing patient population.
Editorial Comment: This document provides an important roadmap for providing optimal outcomes for PCI in patients with complex coronary artery disease – Its more than “getting out of the lab”! it’s about getting optimal acute and late results. In the current era of COVID, certain of these recommendations become particularly important in attempting to reduce hospitalVIEW
De Rosa S, Spaccarotella C, Basso C, et. al. European Heart Journal, ehaa409,
Early in the 2020 COVID – 19 outbreak, one-week acute myocardial infarction (AMI) nationwide data from 44 Italian hospitals were compared to the equivalent week in 2019.
- Admissions were reduced for AMI (48.4%, p < 0.001); STEMI (26.5%, p < 0.009) and NSTEMI (65.1%, p < 0.001).
- Mortality increased for all groups: AMI – 2.8 to 9.7% (p < 0.001); For STEMI – 4.1 to 13.7% (p < 0.001) for NSTEMI; 1.7% to 3.3% (P = NS).
- Similarly, ICU Heart Failure admissions were reduced by nearly half (46.8%, P = 0.005) in 2020.
- Major AMI complications (cardiogenic shock, life-threatening arrhythmias, and cardiac rupture/ventricular septal defect (VSD) or severe functional mitral regurgitation) doubled from 7.4% in 2019 to 15.7% in 2020 (p = 0.001).
- Reductions in STEMI admissions were less significantly less for women (41.2%, P + 0.011) while for men admissions were less, but not significantly (17.8% P + 0.191).
- The rate of coronary angiography for STEMI patients was similar for both years – 94.5% vs. 94.9%, P = NS).
- NSTEMI PCI decreased 13.3% (P = 0.023) from 76.7% of patients in 2019 to 66.1% of patients in 2020.
- 7% of STEMI patients were COVID – 19 positive, with high mortality rate (28.6%), but despite this high rate for the COVID – 19 positive patients, the mortality for non-infected STEMI patients remained significantly higher for 2020 compared to 2019 (P = 0.018).
- Stated but not numerically documented, the time of first medical contact to PCI was much greater in 2020, emphasizing time to revascularization as well as primary PCI are critical factors.
The authors note that not only were the in-hospital death and complication rates higher among AMI patients but the surviving, untreated AMI patients likely represent a major risk for delayed complex requirements for revascularization and treatment for heart failure.VIEW
Soltesz E, Surgical Director of Cleveland of the Kaufman Center for Heart Failure and Recovery, from a recent Tall Rounds online CME activity from Cleveland Clinic covering COVID-19 and the heart published online In Consult QD.
This summary describes the uses and potential limitations of Extracorporeal membrane oxygenation (ECMO) as well as other mechanical Circulatory (MCS) Devices.
- Circulatory support in COVID – 19 patients is likely most effective for single organ system disease such as acute respiratory distress syndrome (ARDS) and/or cardiogenic shock.
- Limitations involve patients with cytokine-mediated myocardial dysfunction plus severe respiratory failure, who despite support have a limited prognosis.
- VV-ECMO and ARDS. (Extracorporeal Life Support Organization – ELSO).
- Contraindications include: older age, mechanical ventilations >7days; multiorgan failure.
- VV-ECMO Oxygen indications focus on the ratio of arterial oxygen partial pressure to fractional inspired oxygen (PaO2:FiO2)
- VV ECMO indicated if PaO2:FiO2 ≥ 150 mmHg and
- pH < 7.25 with PaCO2 ≥ 60 mmHg for > 6 hours.
- For those with PaO2:FiO2 < 150 mmHg and
- PaO2:FiO2 < 80 mmHg for > 6 hours
- PaO2:FiO2 < 50 mmHg for > 3 hours
- pH < 7.25 with PaCO2 >60 mmHg for > 6 hours.
- Challenges to VV-ECMO include:
- Prolonged ECMO support requires – up to 3 weeks due to slow lung healing.
- Systemic inflammation producing a prothrombotic state requiring large heparin and/or bivalirudin dosages.
- Potential ECMO induced advancement of of COVID – 19 to other organ systems.
- Hemodynamic Support for the Management of Cardiogenic Shock
- Optimal for left ventricular failure from a viral myocarditis – as an isolated organ problem.
- Goals of Support
- To provide adequate tissue perfusion (To break the shock spiral)
- Unload the injured ventricle serving as a bridge to recovery, transplant or a permanent device.
- Potential Devices:
- Veno-arterial ECMO (VA-ECMO)
- Advantages – can be implanted at bedside and provides full, biventricular support
- Disadvantages – Lack of ventricular unloading adversely effecting left ventricular recovery (LV) while increasing risk of lung injury, risk of aortic/LV thrombosis as well as hemolysis. Lastly, it is unable to uncouple the left and right ventricles challenging the ability to predict next requirements. Ambulation generally not possible.
- Advantages – Completely unloads the LV, protecting the lungs. Long term support is possible beyond one month with the larger devices. In addition, it has a low rate of hemolysis Ambulation is feasible with axillary cannulation (often surgical).
- Disadvantages – Surgical implantation requires surgery and transesophageal echocardiogram for placement which possibly increases increased risk to personnel.
- Temporary right-ventricular assist devices (RVADs)
- Device types – ProtekDuo/TandemHeart, CentriMag and Impella RP
- An oxygenator can be spliced in to provide an oxy-RVAD configuration.
- Specific management:
- Combined devices – Frequently beneficial – VA ECMO with combined Impella for unloading.
- Heart Team Decisions critical
- In appropriately selected patients, particularly with COVID – 19, these devices can be lifesaving.
Safe Reintroduction of Cardiovascular Services during the COVID-19 Pandemic: Guidance from North American Society Leadership – Part 2 Focusing on Invasive Cath Lab Procedures Part 2 of 2
The authors introduced a table of considerations for the level at which to reinstitute cardiovascular (CV) Services. Levels of patient and personnel risk COVID Risk in conjunction with local health officials and hospital capabilities and availability of PPE and other hospital services.
Recommendations are based on 3 Response Levels:
Level 2 – Reintroduction of some services.
- STEMI – PCI for most patients unless diagnosis unclear and Patient’s COVID Status in question. Exception is lab that routinely treats with thrombolytics.
- ACS/NSTEMI – PCI for High Risk, Medium Risk – selective decisions and low risk initiate medical therapy.
- Stable Coronary Artery Disease (CAD): Focus on High Risk, Symptomatic Patients. Stable and moderate risk patients deferred.
Level 1 – Reintroduction of most services.
- STEMI – Same as Level 2.
- ACS/NSTEMI – Definite angiography for High-Risk patients and now inclusion of Medium Risk Patients. Low Risk patients – consider selective angiography.
- Stable CAD – Stable patients with moderate risk. Truly stable patients remain deferred.
Level 0 – Reintroduction of regular services.
- ACS/STEMI – Same as Level 1 & 2.
- NSTEMI – Routine management without restrictions.
- Stable CAD – Routine management
Note: These represent a composite of concepts gleaned from multiple sources, formal Society recommendations, webinars physician discussions aa well as a variety of social medical posts and discussions. These are meant to be considerations and not guidelines nor do they represent the views of any specific society.
- Important to minimize need for prolonged hospitalizations and/or ICU bed or ventilator use from complications delaying prompt discharge post an invasive procedure.
- Importance of minimizing hospital and ICU bed use from procedures as “insurance” against a sudden increase in COVID – 19 use. Maintaining a critical level of protected ICU beds is critical to continued reintroduction of procedures.
- Minimizing patient risk by scheduling procedures for physicians who are not covering COVID – 19 patients elsewhere and are COVID test negative.
- Screening patients for COVID – 19 to avoid procedure lab and staff contamination.
Maximizing Through-put considerations:
- Triage patients to perform procedures on the highest risk patients first.
- Communicate with further “delayed” patients so they recognize that if symptoms change they notify the Team promptly or seek medical attention promptly depending on the severity of symptoms. This concept seems critical to avoid greater delayed patients assuming they don’t have a problem because of the continued delay and ignoring a symptom change.
- For a given day’s schedule, arrange patients in the reverse order of the likely risk of a complication – doing the most complex last (I know it seems counter-intuitive) but the goal is to get as many patients done before a possible ICU admission might truncate the remainder of a day’s schedule.
Procedure Considerations to minimize hospital days:
Review patient’s clinical and procedure parameters carefully before proceeding. The goal is to development a plan to optimize outcomes while minimizing risk of complications. (Thus, minimizing use of hospital ICU and general beds). It is important to balance optimal outcomes with safety.
Important factors to assess:
- Bleeding risk
- Optimal access site(s) based on vascular disease, bleeding risk and operator and lab experience
- Consider a closure device if anatomically feasible and operator is experience. This is not the time for on-job training.
- Risk of acute kidney injury (AKI).
- Hydrate well and be sure hemodynamically stable with compensated heart failure.
- Extent of revascularization needed – while “staging” maybe seen as a simple way to reduce risk but staging adds to total procedures and additional hospital days. Complete revascularization is the standard for optimal outcomes and is optimally accomplished at a single setting – And reduces hospital days.
- A useful consideration is to use p-VAD (Impella) hemodynamic support for high-risk cases to increase the probability of ideal outcomes in terms of completeness of revascularization, optimal lesion results and potentially reducing the risk of AKI. Optimal results reduce initial hospital time but also reduce the need for repeat hospitalizations for complications such as acute stent closure.
- Post-procedure before discharge, optimize patient education and availability of needed medications – again to maintain a good outcome and lessen readmission.
- Insure family support and follow up including contact for questions.
A final thought:
- While all of these measures are important in the current reintroduction of cardiac procedures, all of them support sound practice principles so that optimizing through-put is not a “tainted” business concept but supports good practice.
George W. Vetrovec, MD, MACC,MSCAI
Safe Reintroduction of Cardiovascular Services during the COVID-19 Pandemic: Guidance from North American Society Leadership Part 1 of 2
Wood DA, Mahmud E, Thourani VH, et.al. Safe Reintroduction of Cardiovascular Services during the COVID-19 Pandemic: Guidance from North American Society Leadership, Journal of the American College of Cardiology (2020), doi: https://doi.org/10.1016/ j.jacc.2020.04.063.
- A consortium entitled the North American Cardiovascular Societies has published a document describing considerations in reestablishing cardiovascular (CV) services in the setting of COVID – 19.
- The need for CV services is critical as many stable but high-risk patients have been deferred along with more routine cases, all potentially magnified by a subset of patients who have deferred seeking evaluation or treatment who are likely to present with more complex or serious and/or acute problems.
A Summary of strategies include:
- Ethical considerations – should include care decisions based on maximum benefit vs. risk of spreading the virus emphasizing that decisions should be fair given various ethnic and social risks.
- Decisions must be made in conjunction with local and regional public and other healthcare administrations and leaders to assure plans meet the needs of a community while representing the needs of high-risk CV previously deferred patients.
- Imperative in the decision process is the protection of patients and Health Care Workers including appropriate distancing, testing for COVID – 19 prior to non-urgent procedures and effective PPE. Noninfected patients and staff need to be protected from the risk of exposure to COVID – 19 patients.
Part II: Specific Practice recommendations from this document will be presented separately.VIEW
Supplement to: Anderson JL, Morrow DA. Acute myocardial infarction. N Engl J Med 2017;376:2053-64. DOI: 10.1056/NEJMra1606915
Specifically pages 6-7 regards Mechanical complications
AMI with mechanical complications includes free wall (cardiac tamponade) or septal rupture (acute Ventricular Septal Defect [VSD]), papillary muscle dysfunction or disruption (acute mitral regurgitation) and ventricular aneurism.
Mechanical complications require prompt diagnosis and high-risk corrective surgery. Surgical outcomes, while associated significant mortality represent the outcomes that succeed no surgery.VIEW
Impact of coronavirus disease 2019 (COVID-19) outbreak on outcome of myocardial infarction in Hong Kong, China
Tam C-CF, Cheung K-S, Lam S, et al. Impact of coronavirus disease 2019 (COVID-19) outbreak on outcome of myocardial infarction in Hong Kong, China. Catheter Cardiovasc Interv. 2020;1–4. https://doi.org/10. 1002/ccd.28943
- Impact of COVID – 19 extends beyond the effects of direct infection to include changes in human behavior which may contribute to acute myocardial infarction (AMI) treatment delays.
- Patients presenting with AMI (STEMI and NSTEMI) from Queen Mary Hospital in Hong Kong were divided into two groups: 11/1/2019-1/24/2020 (Group 1) and 1/25 – 3/31/2020 (Group 2).
- Group 1 represents “Baseline” and Group 2 represents a period of time post the Hong Kong COVID – 19 response.
- Overall average Hospital Emergency Visits declined Group 1 – 327/day vs. Group 2 – 231/day.
- Of 149 patients with AMI during this time, Group 2 patients tended to present later relative to first medical contact to door time.
- There was a non-significant trend to more deaths for Group 2 with later delays in seeking treatment.
- For group 2 patients, the composite of in-hospital death, cardiogenic shock, mechanical circulatory support and VT/VF were significantly higher for Group 2.
- Multiple factors may contribute to these outcomes but clearly a treatment delay seems to play a significant impact on these results.
Hendren NS, Grodin JL, Drazner MH. Journal of Cardiac Failure (2020). doi: https://doi.org/10.1016/j.cardfail.2020.05.006
- The authors describe an acute COVID-19 cardiovascular syndrome, termed ACovCS reflecting the cardiovascular and thromboembolic complications.
- These complications include:
- Acute coronary syndrome with coronary obstructive disease (CAD)
- Acute myocardial injury without CAD
- Heart failure
- Cardiogenic Shock
- Plus – Arrhythmias, pericardial effusions, cardiac tamponade
- Thrombotic complications include stroke, pulmonary embolism and deep vein thrombosis.
- Cardiovascular Presentations can infrequently be isolated but more commonly occurs in conjunction with typical pulmonary disease
- Distinguishing the groups can be a challenge but markers such as troponin can be helpful as to true cardiac vs. a primary pulmonary presentation.
- For patients with predominant cardiac disease shock is likely cardiac as opposed to predominant Pulmonary cases where the shock may be more likely septic.
- Multiple clinical, genetic, environmental and social factors determine the risk of as well as the severity of infection.
- Categorization by this format should allow an effective diagnosis, treatment, and future research.
Vetrovec GW. ACC.org Interventional Section online 5/13/2020
Attached Poll addressed “returning to Normal” for in and outpatient cardiovascular care.
Relative to in-patient STEMI Management, fewer than 8% are using thrombolytics as a primary treatment of STEMI and the remainder are using or continuing Primary PCI (over 60%) while one third are still making decisions on a case by case basis.
Regards outpatient management, roughly two-thirds favored beginning testing with the majority including invasive testing in the plan. One third were still awaiting COVID – 19 numbers before proceeding.
The time frame for this poll was the past two weeks so a current poll might be somewhat more progressive.
Overall the results are favorable for a move to normalcy.VIEW
Milligan GP, Alam A, Guerrero-Miranda C. Journal of Cardiac Failure published on line: https://doi.org/10.1016/j.cardfail.2020.05.00
- In COVID – 19, Echoes may be limited in scope for safety so specific findings are important.
- The mechanism of Acute Cor Pulmonale (ACP) occurs in the setting of ARDS secondary to hypoxemia, pulmonary edema and microvascular thrombosis producing acute right ventricular (RV) afterload.
- Biomarkers (Troponin and brain natriuretic) predict extent of D-dimer elevation and mortality, recently confirmed at autopsy with micro pulmonary thrombosis.
- ACP findings on point of care echocardiograms ultrasound:
- RV enlargement on apical 4 chamber view with RV area >60% of Left Ventricular (LV) area at end-diastole.
- A “D-shaped” ventricular septum caused by a lengthened RV contraction best seen in the parasternal short axis at end-systole
- Reduced systolic excursion of the tricuspid annular plane.
- McConnell’s sign (Regional RV dysfunction characterized by akinesia in mid free wall but preserved apical wall motion.) A specific echocardiographic sign of acute pulmonary embolism.
- The authors recommend use of a right heart catheterization to optimally understand the complex and conflicting hemodynamics of hypoxemic pulmonary vasoconstriction and elevated positive end-expiratory pressure (PEEP) impacting RV preload and afterload.
- A pulmonary artery catheter can support optimization of cardiac output, RV preload as well as pulmonary vascular resistance based on choosing and titrating treatments such as inhaled pulmonary vasodilators and inotropic support while limiting the potential risk of adverse complications such as cardiogenic pulmonary edema.
- The authors recommend determining and treating the specific cardiac abnormalities, emphasizing that the RV, not infrequently, is the most effected chamber requiring support.
TERSALVI G, VICENZI M, CALABRETTA D, BIASCO L, PEDRAZZINI G, AND WINTERTON D.
In China the incidence of Troponin elevation was upwards of 28%, with higher elevations predicting a higher risk of ICU admission and subsequent death. Patients with a troponin elevation are more likely to be elderly and have risk factors of hypertension, coronary heart disease and/or diabetes.
- Four possible mechanisms of troponin elevation are presented:
- Myocarditis – myocardial involvement has been documented with other coronavirus species but so far not with COVID – 19 but presumed myocardial inflammation seems relatively common is likely to represent some cases of troponin elevation
- Microangiopathy – Damage to small vessels in patients may contribute to troponin elevations along with secondary spasm and thrombotic occlusions. Contributing further is likely a secondary vasculitis that occurs in some patients with elevated troponins.
- Myocardial Infarction – Likely occurs frequently based on other studies which suggest that plaque rupture from vascular risk or infection could be playing a role in the troponin elevations by a variety of observations.
- Cytokyne Storm – Potentially a cause to explain the troponin increases. The patents with cytochrome storm havw significant stress on the myocardium.
- In summary the COVID – 19 virus is very strong which allows a catecholamine surge which contributes to the risk.
Question: What are the cardiac characteristics of COVID – 19 patients presenting with STEMI.
Population: This report describes the angiographic findings and outcomes of 28 COVID – 19 patients who presented with STEMI from hospitals in the Lombardy Region of Italy.
- Presentation – 28 patients – 25 with localized ST elevation (89.3%) and 3 with a new LBBB (10.7%).
- Mean age -68+11 years, 28.6% women, 71.4% men.
- Risk factors included Diabetes 32.1%, chronic kidney disease 28.6% and prior myocardial infarction 10.7%.
- STEMI was the first clinical manifestation of COVID in 24 patients (85.7%) and COVID – 19 status was not known at the time of coronary angiography. The other 4 patients developed STEMI during hospitalization.
- Echocardiography was performed in all patients with 23/28 (82.1%) having segmental wall motion changes.
- At coronary angiography, 17 (60.7%) patients had a culprit lesion treated with PCI; 11 patients (39.3%) had no significant obstructive disease.
- At mean follow-up of 13 days, 11 patients died (39.3%); 16 patients (57.1%) were discharged and 1 patient was still hospitalized in the ICU.
- Thus ~40% of STEMI patients with COVID – 19 had no significant coronary disease reaffirming the potential harm of treating with routine thrombolytics. Data is not available to differentiate type 2 myocardial infarction from COVID – 19 myocarditis or other unique etiologies such as COVID induced endothelial dysfunction and/or myocarditis or cytokine storm.
- While the numbers are small, the report emphasizes the point that acute STEMI presentations may be quite different in the setting of COVID – 19.
Association of Treatment Dose Anticoagulation with In-Hospital Survival Among Hospitalized Patients with COVID-19
Background: COVID – 19 appears to be associated with a hypercoagulable state manifested by frequent abnormalities of clotting and observed thrombotic clinical events.
Clinical Question: Does the use of systemic anticoagulants (oral, subcutaneous or intravenous) have a positive clinical impact on outcomes for COVID – 19.
Study: Single-center (Mount Sinai Health System in New York City), retrospective analysis of the effect of a therapeutic anticoagulant (AC) treatment dose on the outcome of patients with laboratory diagnosed COVID – 19.
- Of 2773 hospitalized patients with COVID – 19, 786 (28%) were treated with systemic, therapeutic doses of AC at a median time to AC of 2 days.
- Patients treated with AC had an In-hospital mortality of 22.5% with a median survival of 21 days; patients not receiving AC had a 22.8% mortality with a median survival of 14 days.
- AC patients more often required mechanical ventilation (29.8 vs. 8.1%, p<0.001).
- Mechanical ventilation was required in 395 patients with a mortality of 29.1% and a median survival of 21 days for AC patients compared to a mortality of 62.7% and median survival of 9 days for those not receiving AC.
- Major bleeding was low in both groups with a non-significant increase in bleeding events 3.0% for the AC group compared to 1.9% for the non-anticoagulated patients (p=0.2) including approximately 1/3 of events before the introduction of treatment in the AC group.
- Bleeding events were more common in intubated patients regardless of whether or not they received AC (7.5 vs. 1.35%).
- In summary, while this retrospective study has limitations, Given the recognized frequent hypercoagulability of CODID – 19 patients and the associated observed frequent thrombotic events, a prospective analysis of the impact of AC is warranted.
Li Y, Li H, Zhu S, Xie Y, Wang B, He L, Zhang D, Zhang Y, Yuan H, Wu C, Sun W, Zhang Y, Li M, Cui L, Cai Y, Wang J, Yang Y, Lv Q, Zhang L, Xie M, Prognostic Value of Right Ventricular Longitudinal Strain in Patients with COVID-19, JACC: Cardiovascular Imaging (2020), doi: https://doi.org/10.1016/j.jcmg.2020.04.014.
Study Question: The right ventricular (RV) is susceptible to acute changes secondary to volume overload. Such changes appear to be a potential predictor of COVID – 19 mortality. Because standard echocardiographic parameters are not optimal to assess such changes, the focus of this report Is whether echocardiographic derived right ventricular longitudinal strain (RVLS) is a useful predictor to identify right ventricular function changes as a risk for adverse COVID 19 outcomes.
- Consecutive echocardiograms from 120 consecutive patients with COVID – 19 were analyzed.
- RVLS was categorized by tertiles of RV function compared to standard RV echocardiographic parameters.
- Patients in the highest tertile of RVLS were more likely to multiple risk factors for adverse outcome in conjunction with RV failure including higher D-dimer, invasive mechanical ventilation, greater acute heart injury, acute respiratory distress syndrome (ARDS), deep venous thrombosis and mortality.
- Of 18 patients who died, non-survivors demonstrated greater RV enlargement, RV dysfunction and pulmonary artery elevations of systolic pressure.
- RVLS was determined to be a useful predictor of RV dysfunction and worse COVID-19 survival.
- The challenge is to better utilize early recognition of RV dysfunction as a predictor of adverse outcome and intervene early with novel strategies of RV support to hopefully change the course of this patient population.
The authors report an experience of high risk of pulmonary embolism in the setting of COVID – 19 ICU patients – the details of their preliminary observation follow.
- Reported population: 197 confirmed COVID – 19 patients with an ICU Pneumonia admission.
- Pulmonary Embolus (PE) was diagnosed in 20.6% within 1-18 days, medial 6 days during the ICU admission.
- A Comparison group of 196 patients from the same period in 2019 had a 6.1% incidence of PE.
- Thus, the COVID – 19 population showed an absolute increase in the PE incidence of 14.4%.
- A second comparison noted the risk of PE (7.5%) was half as frequent in 40 ICU admissions for Influenza in late 2019.
- COVID – 19 patients D-Dimers, plasma factor VIII activity and factor Willebrand antigen levels consistent with an increased risk of PE.
- When diagnosed with PE, 20/22 COVID – 19 patients were on Guideline recommended prophylactic antithrombotic treatment (UFH, LMWH). In addition, one patient was on UFH for atrial fibrillation and one patient was on therapeutic fluindione (a vitamin K antagonist) for DVT.
- The associated incidence of DVT was lowest in the COVID – 19 group compared to the other two groups.
- The report has potential biases – first, the decision to perform Computer Tomography Pulmonary Angiography was based on clinical decisions, not for the entire populations: in addition, the population tends to be obese which could impact results.
- In summary, this preliminary report form France suggests that ICU patients with COVID -19 infection are at significantly increased risk for acute PE despite prophylactic anticoagulants.
This report analyzed data on 8910 patients with COVID – 19 from the International Surgical Outcomes Collaborative (Surgisphere) Registry including 169 hospitals located in 11 countries from Asia, Europe and North America. Overall 515 patients died (5.8%) in hospital, while 8395 survived to discharge.
Existing patient characteristics independently associated with in-hospital mortality (shown as % with and without the condition) include:
- Age greater than 65 years (10.0 vs. 4.9%)
- Male sex (6.3 vs. 5.0%)
- Cardiovascular risks
- Coronary Artery Disease (10.2% vs. 5.2%)
- Heart Failure (15.3 vs. 5.6%)
- Cardiac Arrhythmia (11.5 vs. 5.6%)
- COPD (14.2% vs. 5.6%)
- Current Smokers (9.4% vs. 5.6%)
- CV Treatment
- Statins (4.2% on vs. 6% not on – favorable)
- ACE/ARB overall safety (ACE 2.1% on vs. 6.1% not on – favorable; ARB 6.8% on vs. 5.7% off – neutral).
This study reaffirms the significant increased mortality risk for patients with cardiovascular disease or risk factors and importantly, supports prior retrospective reviews regards the safety of ACE/ARB treatmentVIEW
The Authors explored the incidence and characteristics of out of hospital cardiac arrests (OHCA) in 4 regions of the Lombardy region of Northern Italy using the Lombardia Cardiac Arrest Registry for the first 40 days of the outbreak between 2/21/2020 (first regional case 2/20/2020) to 3/31/2020. These statistics were compared to the same 40 days in 2019. There findings are as follows:
- During the 2020 Period 362 cases OHCA were identified, compared with 229 cases in 2019 (an increase of 58%).
- Medical causes and at home events increased 6.5 and 7.3% respectively with a 11.3% increase in unwitnessed OHCA.
- In 2020, median EMS arrival time was 3 minutes longer.
- Bystander CPR was 15.6% lower in 2020.
- In patients with an EMS resuscitation attempt in 2020, out of hospital death was 14.9% higher.
- The cumulative incidence of OHCA was highly associated with the COVID – 19 cumulative incidences.
- Overall there were 133 additional OHCA events in 2020 of which 103 were suspected COVID patients (87) or known COVID patients (16).
- Thus, the 77.4% increased incidence of OHCA in 2020 was reasonably accounted for by COVID – 19 infection.
- Nearly one fourth of the OHCA events otherwise not accounted for in the Lombardia Region are likely attributable in part to acute STEMI (and potentially other potentially lethal acute events). It is likely that most of this increase in mortal events reflect patients not seeking prompt medical attention for acute symptoms because of fear of COVID – 19 exposure if seen at a hospital.
Advanced Pulmonary and Cardiac Support of COVID-19 Patients: Emerging Recommendations From ASAIO—A “Living Working Document”
The authors provide a comprehensive review of the pathophysiology, diagnostic issues, pharmacology, mechanical pulmonary, cardiac support and COVID -19 ASAIO Recommendations emphasizing the treatments for ARDS. The latter topics are what make this document most useful and educational for all clinicians. These latter topics are the focus of the Key Points.
- There are tradeoffs between optimal and what’s available. What follows is a stepwise outline of therapies reflecting the usual progression recognizing variation occur which require modifications.
- Pulmonary Support
- Non-invasive (ex. CPAP/BIPAP) is acceptable for moderate hypoxemia.
- Invasive ventilation with limits on end tidal volume and pressure in ARDS.
- Prone position mechanical ventilation is often used for ARDS to improve basal lung aeration.
- Pulmonary and cardiac support
- Persistent hypoxemia – consider extracorporeal and membrane oxygenation for systemic oxygenation commonly provided by V-V ECMO.
- Cardiogenic shock occurs in a subset of COVID – 19 patients and in salvageable patients warrants focus on left ventricular function which is not always accurately portrayed by LVEF alone, prompting a clinical assessment of adequacy of both right and left cardiac performance.
- While V-V ECMO supports oxygenation in the setting of cor pulmonale, direct RV support is necessary to increase right sided output. Likewise, LV support is needed for cardiogenic shock and maybe provided by V-A ECMO as well as biventricular support using V-V ECMO and pVAD (Impella) for LV support.
- Conversely if total support is provided by V-A ECMO, use of pVAD (Impella) is ideal to unload the LV; the so-called ECPELLA configuration. The Impella use provides an opportunity for prolonged LV support, while potentially minimizing complications.
- These are challenging, often prolonged cases in patients who commonly have significant co-morbidities. Institutions are somewhat limited by their capabilities and realistic expectations for an individual patient’s probable recovery.
Given anecdotal and published reports of decreased STEMI presentations in the face of COVID – 19 infection, a recent ACC.org Poll investigated US respondents assessment of STEMI numbers and extended the question to better understand suspected reasons for the reduced numbers of STEMIO presentations.
- Overall there were just at 500 responses to the two questions:
- Have you noted a decline in STEMI and NSTEMI admissions to your hospitals?
- If reports of fewer STEMI and NSTEMI cases are confirmed, what is the most likely reason?
- 6% noted no change, 23% noted a <50% decline while over 50% of respondents thought there had been more than a 50% decline, including 15% who noted their hospital was seeing no MIs.
- Regards reasons for the decline – 50% thought the issue was under-recognition due to delayed presentations.
- About 18% thought the decline was the result of patients going to smaller, less crowded hospitals.
- 32% of respondents thought the reduction was secondary to less events due to less job stress with shelter in place orders.
- The findings of lower hospital STEMI events seems broad-based including reports from Europe and the USA, while the reasons are less clear but likely relate to patients not seeking appropriate care – a challenge that needs significant public education
Helms J, et. al. Neurologic Features in Severe SARS-CoV-2 Infection: Letter to the Editor, NEJM. Published April 15, 2020: DOI: 10.1056/NEJMc2008597.
Study Background: The authors describe neurologic features identified in two French Hospitals between 3/3-4/3/2020 comprising 64 patients admitted with COVID – 19 acute respiratory distress syndrome (ARDS). The report encompasses the 58 patients who were evaluated in the ICU without neuromuscular blockade at the time of examination by an intensivist and had a neurological evaluation before death. Median age was 63 years and the SAP Score II was 52 (scale ranges form 0-163, with higher values reflecting greater illness severity). Seven patients had prior neurological diagnoses including partial epilepsy, mild cognitive impairment and transient ischemic attack. Surprisingly only 8/49 (16%) patients had fever at the time of examination making this an unlikely cause of the neurological findings and reaffirming the low reliability of this finding for general screening.
- Analysis was complicated by timing of patient examination: 8(14) on admission before treatment, 39 (67%) after sedation and neuromuscular blockage were withheld.
- Overall 49/58(85%) of patients exhibited neurological signs
- Agitation was diagnosed in 40(69%) of patients when sedation and neuro-blockage was withheld.
- Confusion was diagnosed in 26 of 40 patients (65%).
- Diffuse cortical tract findings including enhanced tendon reflexes, clonus and bilateral extensor plantar reflexes were noted in 39 patients (67%).
- A dysexecutive (inattention and/or disorientation) was present in 15 of 45 patients (33%).
- MRIs were performed in 13 patients. Despite no focal signs of stroke, hypo perfusion was seen in 11/13 patients and 8 patients had leptomeningeal spaces. Two asymptomatic patients had evidence of a small acute ischemic stroke and one patient a subacute stroke.
- Of 8 patients who underwent an EEG, only nonspecific changes were detected.
- Spinal fluid analysis was performed in 7 patients showed no cells and all were negative for SARS-CoV-2 virus.
- In summary, the incidence of incidence of encephalopathy (confusion and nonspecific neurological findings) was frequent and included a small number of patients with focal findings of acute or subacute ischemic stroke on MRI scanning.
- There is insufficient data to know the contribution of SARS-CoV-2 virus, acute illness, cytokines or medication withdrawal to these findings.
Several other reports have noted stroke and a variety of neurological findings in COVID – 19 patients, emphasizing the need to be vigilant in these patients for neurologic complications.VIEW
Presenting Characteristics, Comorbidities, and Outcomes Among 5700 Patients Hospitalized With COVID-19 in the New York City Area
Richardson S, Hirsch JS, Narasimhan M, Crawford JM, McGinn T, Davidson KW, and the Northwell COVID-19 Research Consortium. JAMA. doi:10.1001/jama.2020.6775Published online April 22, 2020. Corrected on April 24, 2020.
This report describes COVID – 19 patient outcomes for patients admitted to the Northwell Health System from 12 hospitals including New York City, Long Island and Westchester County, New York March 1 – April 4, 2020. There were 5700 admissions of which 2634 were discharged Alive or died by April 4, with the remainder still hospitalized.
- Of the 5700 admissions, mean age was 63 yrs. with 61% males consistent with other studies demonstrating a male preponderance of cases.
- Common comorbidities parallel other reports including hypertension (56.6%), obesity (41.7%), and diabetes (33.8%).
- Presenting clinical findings included Fever (30.7%), respiratory rate >24/min (17.3%) with supplemental O2 in 27.8%. Respiratory co-infection occurred in 2.1%. Thus, fever is not a predominant finding in hospitalized patients.
- Of the 2634 patients discharged dead or alive during the study period, 14.2% these patients had ICU admissions (mean age 68 yrs, 66.5 % male). Mechanical ventilation was used in 14.2% of patients (86% of patients admitted to the ICU) with 3.2% requiring renal replacement therapy.
- Mortality was 21% for the 2634 patients discharged dead or alive by April 4, highly related to having been on mechanical ventilation (88% mortality) and for age >65 years.
- For patients discharged alive, lymphocyte values tended lower with older age.
- These data parallel data from other studies re-emphasizing the risk for patients requiring ICU admission and mechanical ventilation, being over age 65 and male.
- Reassure public that safeguards are available to minimize patient exposure to COVID – 19 in the hospital setting.
- Patients should continue to use the 911 EMS system for symptoms suggestive of acute ischemic symptoms suggesting a heart attack to assure appropriate care.
- Adhere to optimal protection for medical personnel including PPE and masking patients.
- Primary PCI is the standard of care for definite STEMI. After PCI of the culprit artery, PCI of other
- In the setting of COVID – 19 presentations may be deceptive – thus a careful assessment before going to the cath lab is warranted for patients with diffuse ST – Segment Elevation which might represent acute myocarditis, coronary spasm or other non-traditional presentations which have been reported in COVID – 19 patients and represent cases in which primary thrombolytic treatment would have risk without benefit.
- Patients with severe respiratory dysfunction consistent with ARDS requiring ventilation with multiple co-morbidities may be considered for supportive only care because of a high mortality risk
- Thrombolytic therapy can be considered for patients seen at a non-PCI center unable to be transported to a Primary PCI Center within 120 minutes (current standard recommendation). If thrombolytic treatment is utilized, transfer to a PCI Center is recommended (current guideline) after a phone discussion with the potential accepting center.
- Patients with Cardiogenic Shock and ST Elevation STEMI are considered for urgent invasive therapy and possible hemodynamic support with consideration for intubation before entering cath lab to reduce risk of viral spread with sudden cardiac arrest.
- Patients without of hospital cardiac arrest (OHCA) should be considered for invasive management if they have elevated ST – Segments consistent with infarction and wall motion abnormalities on echocardiography.
- Non-Acute STEMI patients with OHCA should only be considered if hemodynamically unstable.
- NSTEMI should be managed medically unless hemodynamically unstable or have high risk characteristics – Grace Score > 140.
- Safety remains of utmost importance – ideally with a designated cath lab (and negative pressure if available) for these patients and appropriate PPE for all involved.
ASE Statement on Protection of Patients and Echocardiography Service Providers During the 2019 Novel Coronavirus Outbreak
Endorsed by the American College of Cardiology© 2020 American Society of Echocardiography
Kirkpatrick JN, Mitchell C, Taub C, et. al. JACC: https://doi.org/10.1016/j.jacc.2020.04.002
- Priority is determining the importance of a study vs. staff risk for the value of information
- Delay non-critical studies.
- Plan the study ahead to know the images needed to answer the clinical question(s), while minimizing study time (Personnel exposure time).
- The decision to use Ultrasound Enhancing Agents (UEA) ideally should be made ahead a time to avoid procedure prolongation for preparing.
- Restrict students and/or inexperienced technologists to minimize scan time.
- Rapid review and documentation of Echo results with communication with the appropriate staff.
- Staff should practice appropriate safety precautions (PPE, hand-washing, etc.)
COVID-19 pandemic and cardiac imaging: EACVI recommendations on precautions, indications, prioritization, and protection for patients and healthcare personnel
Skulstad H, Cosyns B, Popescu BA, et. al. European Heart Journal – Cardiovascular Imaging (2020) 0, 1–7 doi:10.1093/ehjci/jeaa072
Key Points (For patients with suspected or confirmed COVID – 19 Infection)
- Target studies to cases in which an imaging test can provide clinically important management information using the most appropriate modality to obtain the needed information.
- Recognize and assess the risk of a study to personnel or equipment relative to the contamination of personnel and/or other patients related to transportation.
- Appropriate personnel protective practices and thorough and complete equipment cleaning between cases are critical for ultimate safety.
- Consider Bedside echocardiography (including POCUS) with limited/focused studies to answer the specific question being addressed. TEE high risk for personnel exposure – consider alternative imaging modalities.
- Chest CT with modifications can be useful for multiple evaluations; pneumonia and coronary anatomy.
- Left ventricular can be assessed during coronary angiography.
- CMR for myocardial metabolic functional evaluation – particularly assessing myocarditis is an important to modality.
Interim Guidance for Basic and Advanced Life Support in Adults, Children, and Neonates With Suspected or Confirmed COVID 19
From the Emergency Cardiovascular Care Committee and Get With the Guideline-Resuscitation Adult and Pediatric Task Forces of the American Heart Association in collaboration with the American Academy of Pediatrics, American Association for Respiratory Care, American College of Emergency Physicians, The Society of Critical Care Anesthesiologists, and American Society of Anesthesiologists: Supporting Organizations: American Association of Critical Care Nurses and National EMS Physicians.
Edelson DP, Sasson C, Chan PS, et.al. Circulation
Guidelines written regards CPR during the COVID – 19 Pandemic with a major focus on professions safety of Resuscitation Team Members in managing patients known or at risk for COVID – 19 infection.
- Interim Guidelines emphasize protecting responders
- Assess risk of infection vs. the likelihood of a successful resuscitation –Older patients with multiple comorbidities are less likely to survive
- Providers should utilize PPE including a face-mask.
- Hands-only CPR can be performed for out of hospital Cardiac Arrest but some aerosolization can occur even without direct airway management. Ideally a face mask should be placed on the victim as well.
- In-hospital limit personnel in room to be important members of the team; prohibit students or observers.
- For patients with a primary respiratory arrest, consider immediate intubation to minimize aerosolization from breathing bags, high flow oxygen or other used initial treatments.
The New Pandemic Threat: People May Die Because They’re Not Calling 911 There has been a dramatic decrease in Myocardial Infarction presentations worldwide during the current COVID – 19 Pandemic.
- There has been a dramatic decrease in Myocardial Infarction presentations worldwide during the current COVID – 19 Pandemic.
- Multiple reasons for the reduction in infarctions have been postulated but a worrisome and likely significant one is that patients don’t seek care promptly, if at all for symptoms of a heart attack.
- This “New Pandemic Treat” Statement is signed by multiple organizations and is directed to patients – emphasizing the importance of immediately seeking treatment for important heart attack and stroke symptoms.
- Perhaps as physicians are communicating with patients remotely, healthcare professionals might consider downloading and distributing this statement to their patients to combat an important, “indirect” COVID – 19 risk!
- Pass this statement on – its an inexpensive but important “Vaccine” – A 911 Call.
On April 17, CMS announced a plan to begin allowing the elective procedures resume. Below is a brief summary of the requirements.
- States or Regions must meet “Gating Criteria”
- A lowering trend in flu-like illnesses, COVID – 19 Cases/or positive test numbers percentages during a 14 day period.
- An effective COVID – 19 testing program for potentially exposed healthcare workers.
- Reopening Facilities will require.
- Testing equipment.
- Appropriate numbers of workforce for the care of patients.
- Sufficient PPE.
- Being prepared for a potential surge in COVID – 19 Cases.
- Optimal strategy is to have hospitals establish COVID Free Units (“non-COVID Care (NCC) zones”)
- Staff only work in these areas (No cross rounding between COVID – 19 Patients or units and NCC area.
- Such units will require strict screening for patients before entry and for staff.
- Screening emphasizes clinical assessment for recent symptoms and fever.
Lisa Rosenbaum, M.D. NEJM DOI: 10.1056/NEJMms2009984 Published April 17, 2020.
- Dr. Rosenbaum’s comments are in the New England Journal of Medicine’s Medicine and Society Section and succinctly points out with case examples patients who because of the understandable focus on COVID – 19 as a disease and as a risk to patients and medical staff receive non-standard care for non-COVID – 19 related serious medical problems. Examples include
- Patients with serious cancers who either feel to have missed the value of a “real” multidisciplinary (and usually “face to face”) discussion of options and plans or even potential delays in treatments with unknown consequences.
- Patients with potentially life-threatening Acute Coronary Syndromes who present with accelerated symptoms but without ECG/Biomarker evidence of infarction are sent home – and only if fortunate to return in time and undergo appropriate coronary angiography.
- A patient whose delay in care for acute myocardial infarction, awaiting assessment of COVID – 19 status (ultimately negative) led to progressive deterioration with cardiogenic shock and ultimately death.
- These are not examples from a remote or rural location but from top tier, major medical centers –
- Reasons include concerns about availability of PPE for staff and a general concern about how to manage no COVID illness in the wake of a Pandemic.
- A recent study (Garcia S, Albaghdadi MS, Meraj PM, et al. Reduction in ST- segment elevation cardiac catheterization laboratory activations in the United States during COVID-19 pandemic. J Am Coll Cardiol 2020 April 9 (Epub ahead of print) demonstrated a 38% reduction in STEMI procedures since the onset of the COVID – 19 Pandemic.
- The focus of risk/benefit in patient care has at times moved from patient to staff in the current Pandemic.
- Dr. Rosenbaum concludes with two comments:
- “Humanity absent sound medical judgment is meaningless.”
- “Yet as we begin to observe fewer admis- sions for common emergencies such as heart attack and stroke, … the need for vigilance about viral transmission need not detract from an equally important message: Covid or no Covid, we are still here to care for you.”
- Standard diseases in the setting of COVID – 19 still exist and still require standard treatments – our challenge is to provide that care safely (for all involved), compassionately, and appropriately.
First successful treatment of COVID-19 induced refractory cardiogenic plus vasoplegic shock by combination of pVAD and ECMO: A case report
Xavier Bemtgen, Kirsten Krüger, David Alexander Supady, et.al: ASAIO Journal Publish Ahead of Print DOI: 10.1097/MAT.0000000000001178
The authors present a 52 y.o. COVID – 19, male patient with a known dilated cardiomyopathy, systolic heart failure and a recent admission for worsening heart failure complicated by a myocardial infarction. The current admission was prompted by cough and shortness of breath. The patient rapidly deteriorated secondary to development of Adult Respiratory Distress Syndrome (ARDS) requiring mechanical ventilation. His course was further complicated by combined cardiogenic and vasoplegic shock (C.I. = 1.8L/min/m2) unresponsive to high doses of vasopressors. On day 3, because of inability to control the shock plus the development of renal failure, a pVAD (Impella CP Smart Assist) was implanted in the cath lab providing 3.5l/min of flow. Lactate normalized and left ventricular end diastolic dimension (LVEDD) diminished. However, the vasoplegic shock persisted requiring continued high dose vasopressors. A V-A ECMO was added day 4 providing 4.5L/min flow. By Day 7 the vasopressors could be withdrawn and the ECMO was changed to a V-V configuration with continued hemodynamic support provided by the Impella. The Impella was successfully weaned at day 19, but V-V ECMO support persists at day 24 suggesting ARDS may be the most resistant of the COVID – 19 complications in this patient.
- First case report of pVAD (Impella) combined with ECMO for treatment of refractory cardiogenic and vasoplegic shock in a COVID – 19 patients presenting with ARDS.
- This case supports the experience that patients of all ages are potentially at risk for severe COVID Complications which are further exacerbated by pre-existing cardiac complications as this patient has coronary artery disease, prior myocardial infarction and a dilated cardiomyopathy with heart failure.
- Severe shock, cardiac and vasoplegic occur in ARDS patients.
- Impella CP support rapidly normalized lactate levels and reduced LVEDD, consistent with Left Ventricular unloading.
- Combined ECMO flow supported oxygenation and provided support to overcome the severe vasoplegic shock, but primarily supported long-term oxygenation.
- Impella provided the necessary hemodynamic support for cardiogenic shock as measured by lactate reduction with associated favorable left ventricular unloading.
Key Points: ST-Segment Elevation in Patients with COVID-19 — A Case Series
Sripal Bangalore, M.D., M.H.A. Atul Sharma, M.D. Alexander Slotwiner, M.D. New York University Grossman School of Medicine New York, NY
Report of patients with documented COVID – 19 from 6 New York Hospitals with ST-elevation on ECG.
- Non-coronary related myocardial injury was defined by a non-obstructive coronary angiogram or in patients not undergoing coronary angiography having no wall motion abnormalities via echocardiography.
- Patient Population – Patients – 18; Mean age – 63 years; Men-83%
- ST-Elevation on admission – 10 ((56%), In Hospital – 8 (44%, median 6-days post-admission); Only 33% had chest pain at the time of ST-Elevation.
- Focal ST-segment elevation was present in 14 patients (78%) – 5 (36%) with normal LVEF despite regional wall motion abnormality in 1 (20%); 8 patients (57%) had a reduced LVEF – regional wall motion abnormalities were present in 5 (62%). (one patient had no echocardiogram);
- Diffuse ST-segment elevation was present in 4 (22%) patients; Normal LVEF with normal wall motion – 3 (75%) patients; LVEF was 10% in one patient with global hypokinesis with an LVEF of 10%.
- Coronary Angiography was performed in 9 (50%) patients; Coronary Obstruction was identified in 6 patients (67%) with PCI in 5 (56%) patients.
- Clinical Diagnosis of Myocardial Infarction – 8 (44%) of patients had higher median peak troponin levels and d-dimer levels than the 10 patients (56%) with myocardial injury unassociated with coronary artery disease.
- Hospital Mortality was 72% (13 of 18 patients) – 4 with diagnosed, traditional myocardial infarction, 9 with non-coronary myocardial injury.
- The etiologies of Myocardial Infarction versus diffuse Myocardial Injury remain unknown and are likely multifactorial given that the presentations were very diverse); Proposed mechanisms include ruptured coronary plaque, hypoxic injury, coronary spasm, microthrombi, direct endothelial and/or cytokine storm.
- Of note, all 18 patients had elevated d-dimer values which have been observed in other COVID – 19 Reports.
- In summary, patients with ST-segment Elevation are high risk despite divergent etiologies which can be coronary occlusion or diffuse myocardial injury. Management remains challenging, but invasive diagnosis may be frequently required to understand and potentially treat the underlying process.
Dr. David D’Alessandro, surgical director, heart transplantation and ventricular assist devices, at Massachusetts General Hospital, presents the case of a 44-year-old woman with COVID-19 who was treated using Impella 5.5 with SmartAssist.
At the time of admission patient presented with chest pain & shortness of breath.
Drs. Seth Bilazarian and Dan Raess provide an update on the management of cardiovascular complications in COVID-19 patients, with a focus on sharing emerging research and best practices.VIEW
Impacto de la pandemia de COVID-19 sobre la actividad asistencial en cardiología intervencionista en España
- Survey of 81 centers in STEMI Network in 17 regions of Spain
- Baseline Before Outbreak data: February 24-March 1, 2020
- During the Outbreak data: March 16-23, 2020
- From an 88% response rate STEMI PCI volume was down 40% with a slight increase in Thrombolytics though Primary PCI is the dominant treatment for STEMI
- They report up to 5% of Interventional Cardiologists had COVID – 19
- The authors conclude that “Scientific Societies and Health Authorities” need to promote STEMI that patients should receive appropriate and timely reperfusion treatment
Note: Only Abstract in EnglishVIEW
Reduction in ST-Segment Elevation Cardiac Catheterization Laboratory Activations in the United States during COVID-19 Pandemic
- Data gathered from 9 US centers with greater than 100 PCIs per year
- March 1, 2020 defined as date of onset of “After COVID” (AC) Before March 1, considered “Before COVID” (BC)
- The “control” BC time frame was January 1, 2020 – February 29, 2020 -14 months
- There is a 38% (95% CI: 26-49; p<0.001) reduction in Cath Lab STEMI activation since the onset of COVID – 19
- Total Site monthly activation for all centers BC was > 180 per month (Av. 23.6 activations/month); AC Site activation was 138 (mean 15.3 per month)
- Reduction in US STEMI activation parallels the reduction of 40% in Spain (Rodríguez-Leor O, et al. REC Interv Cardiol. 2020) posted separately on this A-Cure site
- The authors note that with given social stress, an influenza-like illness and potential “false-positives”, one would have expected an increase in activations.
- Potential causes for a decline (despite ACC/SCAI recommendation to continue primary PCI as standard STEMI management despite the Pandemic) include:
- avoidance of contacting Medical Systems 2nd to concerns of COVID -19 exposure in a hospital
- Misdiagnosis of STEMI
- Pharmacological reperfusion to protect medical staff from COVID-19 infection possible related to limited PPE.
- Close monitoring and reevaluations of treatment strategies including supporting guideline recommendations will be critical going forward to insure that STEMI patients receive appropriate management.
Tavazzi G, Pellegrini C, Maurelli M, et. al. EJHF: https://doi.org/10.1002/ejhf.1828
Case report – First Documented, Biopsy proven, Myocarditis with Coronavirus Involvement
- Flu-like symptoms become acute respiratory failure complicated by Shock with reduced Left Ventricular Ejection Fraction (LVEF) (25%) with lymphopenia and leukocytosis and positive inflammatory markers and cardiac markers (hs‐TnI-4332 ng/L).
- Mechanical ventilation, IABP and V-A ECMO were instituted for hemodynamic and respiratory support.
- Coronary Angiography was non-diagnostic and Endomyocardial Biopsy pathology demonstrated low‐grade myocardial inflammation with an absence of myocyte necrosis. Coronavirus particles were found in macrophages and interstitial cells but viral particles were not definitively identified in cardiac myocytes.
- Cardiac function recovered by day 5 and ECMO and IABP were removed
- On day 13, the patient acutely developed Gram-negative sepsis without cardiac decompensation and died of septic shock.
- Interpretation of the Biopsy findings
- While the clinical presentation was consistent with an acute necrotizing, inflammatory myocarditis, the pathology demonstrated only mild inflammation without necrosis. Viral particles were found in the lungs and based on prior viral illnesses (MERS‐CoV), viral particles frequently appear in other organs. However, no vascular involvement was observed.
- The authors hypothesize that cardiac involvement occurred secondary to a viremia or by an extra-pulmonary transfer of virus via macrophages into the myocardium.
- This is a single case. More are needed to confirm and add to these findings, but the current case illustrates an early viral involvement with a likely later inflammatory response that can lead to large cytokine release.
- Hemodynamic and respiratory support potentially with Interleukin treatment may reduce the severity of the illness
Baseline Characteristics and Outcomes of 1591 Patients Infected With SARS-CoV-2 Admitted to ICUs of the Lombardy Region, Italy
- Reaffirms the high risk for patient’s comorbidities, particularly Hypertension and Cardiovascular Disease with similar findings between Lombardy, Italy and 14 stated in the US
- Risk is also associated with other CV Disease Risk Factors such as Diabetes and obesity.
- Both studies reaffirm increased risk in the elderly which may reflect more comorbidities in older age.
- Respiratory symptoms were very prominent but symptoms related to multiple organ systems were found including Chest Pain
- Reiterate the concern for patients with hypertension and underlying cardiac disease as a severe risk factor and warrant early screening and aggressive management.
Hospitalization Rates and Characteristics of Patients Hospitalized with Laboratory-Confirmed Coronavirus Disease 2019
COVID-NET, 14 States, March 1–30, 2020 CDC COVID 19 data
- Reaffirms the high risk for patient’s comorbidities, particularly Hypertension and Cardiovascular Disease with similar findings between Lombardy, Italy and 14 stated in the US
- Risk is also associated with other CV Disease Risk Factors such as Diabetes and obesity.
- Both studies reaffirm increased risk in the elderly which may reflect more comorbidities in older age.
- Respiratory symptoms were very prominent but symptoms related to multiple organ systems were found including Chest Pain
- Reiterate the concern for patients with hypertension and underlying cardiac disease as a severe risk factor and warrant early screening and aggressive management.
Results of a poll posted on the Interventional Section of ACC.org over the last two weeks assessed planned management strategies of patients with diagnosed or presumed COVID – 19 presenting with STEMI or NSTEMI during the Coronavirus Pandemic. The results from over 1800 participants demonstrate:
For STEMI presentations – Treatment choices were thrombolytics (44%) over traditional primary PCI (33%) while 23% thought decisions should be hospital-based.
For NSTEMI presentations – the predominant treatment choice was medical treatment in the absence of Shock (63%), usual card with risk assessment and appropriate early angiography (21%), while 16% thought decision protocols should be hospital-based.VIEW
An Interview With an Italian Intensivist on the COVID Experience in Italy – American College of Cardiology
- Reaffirms primary presentation is respiratory
- Cardiovascular Involvement is definite; often myocarditis, but concerns of excluding traditional infarction induced by high inflammatory markers.
- Use of Hemodynamic support is used selectively, often with V-V ECMO for oxygenation but other considerations include conversion to V-A ECMO with considerations for Impella unloading (ECPella)
- Challenges in managing cardiogenic shock include limitation of Right Heart Catheterization and the challenges of potentially placing an Impella in the ICU. (See Posted article on A-Cure sight Pappalardo description of ICU Impella Insertion.)
- Deciding on Resource utilization generally targets patients based on blood pressure levels, pressors required and Left Ventricular Ejection Fraction.
The publication summarizes multiple areas of focus:
- Myocardial Injury measured by multiple myocardial and inflammatory markers increases mortality risk – Higher enzyme values = higher mortality.
- Myocardial markers which stabilized or declined were associated with a lower mortality risk consistent with the importance of aggressive management.
- Patients with elevated cardiac markers (e.g. Troponin T) and a history of CV disease had nearly twice the mortality risk (69.4%) compared to patients with elevated cardiac markers but no history of CV disease (37.5%).
The publication summarizes multiple areas of focus:
- Comorbid conditions increasing mortality risk include cancer, hypertension, chronic respiratory disease, diabetes, and cardiovascular disease in ascending risk with mortality risk 10.3% for underlying CV Disease.
- Triage CV patients for early identification and early escalation of care because of the high risk of adverse outcomes.
- Develop protocols for screening and management to optimize an early response to high-risk CV patients – particularly those who develop Acute Myocardial Infarction and Cardiogenic Shock.
- Educate staff on inappropriate personal protection use and catheterization lab management.
This early Washington experience reaffirms that COVID – 19 ICU admissions are most commonly precipitated by severe respiratory insufficiency and hypotension, in older patients with multiple comorbidities.
The resulting mortality was 50% again highest in the oldest patients.VIEW
OBJECTIVE To explore the association between cardiac injury and mortality in patients with
DESIGN, SETTING, AND PARTICIPANTS This cohort study was conducted from January 20,
2020, to February 10, 2020, in a single-center at Renmin Hospital of Wuhan University,
Wuhan, China; the final date of follow-up was February 15, 2020. All consecutive inpatients
with laboratory-confirmed COVID-19 were included in this study.
MAIN OUTCOMES AND MEASURES Clinical laboratory, radiological, and treatment data were
collected and analyzed. Outcomes of patients with and without cardiac injury were
compared. The association between cardiac injury and mortality was analyzed.
RESULTS A total of 416 hospitalized patients with COVID-19 were included in the final analysis;
the median age was 64 years (range, 21-95 years), and 211 (50.7%) were female. Common
symptoms included fever (334 patients [80.3%]), cough (144 [34.6%]), and shortness of
breath (117 [28.1%]). A total of 82 patients (19.7%) had cardiac injury, and compared with
patients without cardiac injury, these patients were older (median [range] age, 74 [34-95] vs
60 [21-90] years; P < .001); had more comorbidities (eg, hypertension in 49 of 82 [59.8%] vs
78 of 334 [23.4%]; P < .001); had higher leukocyte counts (median [interquartile range
(IQR)], 9400 [6900-13 800] vs 5500 [4200-7400] cells/μL) and levels of C-reactive protein
(median [IQR], 10.2 [6.4-17.0] vs 3.7 [1.0-7.3]mg/dL), procalcitonin (median [IQR], 0.27
[0.10-1.22] vs 0.06 [0.03-0.10] ng/mL), creatinine kinase–myocardial band (median [IQR], 3.2
[1.8-6.2] vs 0.9 [0.6-1.3] ng/mL),myohemoglobin (median [IQR], 128 [68-305] vs 39 [27-65]
μg/L), high-sensitivity troponin I (median [IQR], 0.19 [0.08-1.12] vs <0.006 [<0.006-0.009]
μg/L), N-terminal pro-B-type natriuretic peptide (median [IQR], 1689 [698-3327] vs 139
[51-335] pg/mL), aspartate aminotransferase (median [IQR], 40 [27-60] vs 29 [21-40] U/L),
and creatinine (median [IQR], 1.15 [0.72-1.92] vs 0.64 [0.54-0.78]mg/dL); and had a higher
proportion of multiple mottling and ground-glass opacity in radiographic findings (53 of 82
patients [64.6%] vs 15 of 334 patients [4.5%]). Greater proportions of patients with cardiac
injury required noninvasive mechanical ventilation (38 of 82 [46.3%] vs 13 of 334 [3.9%];
P < .001) or invasive mechanical ventilation (18 of 82 [22.0%] vs 14 of 334 [4.2%]; P < .001)
than those without cardiac injury. Complications were more common in patients with cardiac
injury than those without cardiac injury and included acute respiratory distress syndrome (48
of 82 [58.5%] vs 49 of 334 [14.7%]; P < .001), acute kidney injury (7 of 82 [8.5%] vs 1 of 334
[0.3%]; P < .001), electrolyte disturbances (13 of 82 [15.9%] vs 17 of 334 [5.1%]; P = .003),
hypoproteinemia (11 of 82 [13.4%] vs 16 of 334 [4.8%]; P = .01), and coagulation disorders (6
of 82 [7.3%] vs 6 of 334 [1.8%]; P = .02). Patients with cardiac injury had higher mortality
than those without cardiac injury (42 of 82 [51.2%] vs 15 of 334 [4.5%]; P < .001). In a Cox
regression model, patients with vs those without cardiac injury were at a higher risk of death,
both during the time from symptom onset (hazard ratio, 4.26 [95%CI, 1.92-9.49]) and from
admission to end point (hazard ratio, 3.41 [95%CI, 1.62-7.16]).
CONCLUSIONS AND RELEVANCE Cardiac injury is a common condition among hospitalized
patients with COVID-19 in Wuhan, China, and it is associated with higher risk of in-hospital
This website is intended as a resource for clinicians caring for critically-ill COVID-19 patients, based on available evidence and recommendations of governing bodies. The recommendations do not replace clinical judgment or the need for individualized patient care plans.
Section 5 covers Cardiac Complications:
- Acute Cardiac Injury
- Cardiovascular Testing and Consultation
- Acute Coronary Syndromes
- Pericarditis and Myocarditis
Dr. Westenfeld speaking at the 2017 A-CURE Symposium on the clinical efficacy of left ventricular support by Impella during cardiogenic shock relieving pulmonary congestion.VIEW
Dr. Tschöpe discusses the use of prolonged Impella support to successfully bridge patients through cardiogenic shock resulting from myocarditis.
- Dr. Tschope presents clinical and Theoretical concepts regards the potential role of unloading to prevent ventricular remodeling in acute, severe viral myocarditis.
- The presentation emphasizes the potential effect of unloading may be mediated via reduced inflammatory markers with resultant improvement in cardiac function and associated biopsy evidence of reduced inflammation.
- While the presentation antedated the Coronavirus Pandemic, the principles may be applicable to a variety of viral etiologies with more experience.
A-Cure working Group
Dr. Navin Kapur speaks on the relationship between acute cardiac unloading and renal function during myocardial ischemiaVIEW
Surviving Sepsis Campaign: Guidelines on the Management of Critically Ill Adults with Coronavirus Disease 2019 (COVID-19)
Background: The novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is the cause of
a rapidly spreading illness, Coronavirus Disease 2019 (COVID-19), affecting thousands of people around
the world. Urgent guidance for clinicians caring for the sickest of these patients is needed.
Methods: We formed a panel of 36 experts from 12 countries. All panel members completed the World
Health Organization conflict of interest disclosure form. The panel proposed 53 questions that are
relevant to the management of COVID-19 in the ICU. We searched the literature for direct and indirect
evidence on the management of COVID-19 in critically ill patients in the ICU. We identified relevant and
recent systematic reviews on most questions relating to supportive care. We assessed the certainty in the
evidence using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE)
approach, then generated recommendations based on the balance between benefit and harm, resource and
cost implications, equity, and feasibility. Recommendations were either strong or weak, or in the form of
best practice recommendations.
Results: The Surviving Sepsis Campaign COVID-19 panel issued 54 statements, of which 4 are best
practice statements, 9 are strong recommendations, and 35 are weak recommendations. No
recommendation was provided for 6 questions. The topics were: 1) infection control, 2) laboratory
diagnosis and specimens, 3) hemodynamic support, 4) ventilatory support, and 5) COVID-19 therapy.
Conclusion: The Surviving Sepsis Campaign COVID-19 panel issued several recommendations to help
support healthcare workers caring for critically ill ICU patients with COVID-19. When available, we will
provide new evidence in further releases of these guidelines.