Initial computed tomography (CT) chest scan without contrast is performed to rule out pneumonia and/or ground glass appearance, consolidations, and/or pneumonitis indications. CT chest scan with contrast also will rule out pulmonary embolus, which can be a contributing factor to respiratory symptoms, elevation in biomarkers, and a sequela of COVID-19 infection.2

Diagnosis

The 12-lead ECG, serum cardiac biomarkers, and clinical presentation are the predominate tools for diagnosing acute STEMI or NSTEMI. On the 12-lead, ST elevation in 2 contiguous leads in a patient presenting with chest pain or anginal equivalent is diagnostic for STEMI. An ST-segment depression, transient ST-elevation, or new T-wave inversion in 2 contiguous leads, plus positive serum troponin in a patient with chest pain or anginal equivalent, is diagnostic for NSTEMI. Initial ECGs can be relatively normal in NSTEMI patients. In these cases, serial ECGs should be repeated at 15- to 30-minute intervals during the first hour or if symptoms recur.3

Medical Management/Treatment

Initial treatment for suspected STEMI and NSTEMI requires a loading dose of nonenteric coated ASA at 162 to 325 mg (unless contraindicated), nitroglycerin in response to chest pain, and unfractionated heparin based on weight and renal function.3 Table 2 outlines the treatment management for STEMI and NSTEMI.


Continue Reading

Table 2. Medical Management of STEMI and NSTEMI

STEMI1,2
• Activate STEMI team per hospital protocol
• Primary PCI for STEMI, thrombolytic therapy is controversial; use for “low-risk STEMI”* only if interventional cardiologist is unavailable
• Guideline-directed medical therapy: ASA (162-325-mg nonenteric coated), unfractionated heparin, statin, beta blocker (if no bradycardia or cardiogenic shock)
• Dual antiplatelet therapy (DAPT) postcoronary stent intervention requires ASA 81 mg plus a loading dose of 1 of the following selected P2Y12 inhibitors followed by maintenance dosing:
Clopidogrel 75 mg/d or
Prasugrel 10 mg/d or
Ticagrelor 90 mg bid
• Bedside ECG if any clinical uncertainty
• If no angiographic disease, monitor and treat for possible myocardial injury sequela
NSTEMI2
• Check ECG and troponin if clinical suspicion of acute coronary syndrome
• Guideline-directed medical therapy: aspirin, unfractionated heparin, statin, beta blocker (if no bradycardia or cardiogenic shock)
• Assess drug interaction of antiplatelet or anticoagulants
• Cardiac catheterization if high clinical suspicion of acute coronary occlusion. If low suspicion, coronary angiogram is delayed until after recovery of COVID-19 infection.
• Coronary CT angiogram in hemodynamically stable NSTEMI
• Bedside ECG
ASA, aspirin; CT, computed tomography; ECG, electrocardiogram; NSTEMI, non-ST-elevation myocardial infarction; STEMI, ST-elevation myocardial infarction
*Low-risk STEMI defined by inferior STEMI with no right ventricular involvement or lateral AMI without hemodynamic compromise.5

Most MIs occurring concurrently with COVID-19 illness are type 2.6 Type 2 MIs occur because of a consequent mismatch between oxygen supply and demand, usually related to ongoing infection, respiratory compromise, and/or cardiac hemodynamic instability.5

Discussion/Follow-up Care

For patients with COVID-19 and STEMI, percutaneous coronary intervention remains the treatment of choice. For patients with COVID-19 and NSTEMI, conservative therapy is reasonable in hemodynamically stable patients, but hemodynamically unstable patients should be managed similarly to those with STEMI.1

In addition to standard STEMI/NSTEMI post care, follow-up care for patients with COVID-19 and cardiovascular complications should include periodic evaluation every 1 to 3 months with detailed history and physical examination, 12-lead ECG, and 2D/Doppler echocardiographic or cardiac magnetic resonance imaging with late gadolinium enhancement to evaluate cardiac function. If necessary, heart failure therapy should be initiated and maintained as appropriate, with optimization of medications and ongoing monitoring.7

Deedra Harrington, DNP, MSN, APRN, ACNP-BC, is associate professor at the College of Nurse and Allied Health Professions, the University of Louisiana at Lafayette. Dr. Harrington is an advanced practice registered nurse-acute care who works with an inpatient cardiology intensivist group in Louisiana.

Christy L. McDonald Lenahan, DNP, FNP-BC, ENP-C, CNE, is an advanced practice registered nurse in family and emergency medicine who works for an emergency medicine and hospitalist staffing agency. She is also an associate professor at the University of Louisiana at Lafayette and teaches in the masters and doctoral programs.

Frances Stueben, DNP, RN, CHSE, is an assistant professor and Simulation Program Coordinator at the University of Louisiana at Lafayette. She teaches in the graduate and undergraduate nursing programs.

References

1. Long B, Brady WJ, Koyfman A, Gottlieb M. Cardiovascular complications in COVID-19. Amer J Emerg Med. 2020;38:1504-1507. doi:10.16/j.ajum.2020.04.048

2. Dhakal BP, Sweitzer, NK, Indik, JH, Acharya D, William P. SARS-CoV-2 infection and cardiovascular disease: COVID-19 heart. Heart Lung Circ. 2020;29(7):973-987. doi:10.1016/j.hlc.2020.05.101

3. Armsterdam EA, Wenger NK, Brindis, RG, et al. 2014 AHA/ACC guideline for the management of patients with non-ST-elevation acute coronary syndromes. J Am Coll Cardiol. 2014;64:e139-e228. doi:org/10.1016/j.jacc.2014.09.017

4. Zafari AM. Myocardial infarction workup. In Yang EH, ed. MedScape. https://emedicine.medscape.com/article/155919-workup. Accessed March 3, 2021.

5. Ellis KM. Myocardial infarction. In: EKG Plain and Simple. 4th ed. Pearson Education; 2016:311-243.

6. Sandoval Y, Jaffe AS. Key points about myocardial injury and cardiac troponin in COVID-19. J Am Coll Cardiol. Published July 17, 2020. Accessed March 8, 2021. https://www.acc.org/latest-in-cardiology/articles/2020/07/17/08/00/key-points-about-myocardial-injury-and-cardiac-troponin-in-covid-19.

7. Guzik TJ, Mohiddin SA, Dimarco A, et al. COVID-19 and the cardiovascular system: implications for risk assessment, diagnosis, and treatment options. Cardiovasc Res. 2020;116(10):1666-1687. doi:10.1093/cvr/cvaa106

This article originally appeared on Clinical Advisor