On March 6, 2020, the American College of Cardiology (ACC) issued coronavirus disease 2019 (COVID-19) clinical guidance for the cardiovascular care team, “based on the best available published information and expert evaluation.”1 The guidance provides recommendations for the management of patients with acute cardiac complications of COVID-19, precautions specific to patients with underlying cardiovascular conditions, and guidance on cardiac-specific preparedness for the virus.
After urging healthcare professionals to start by protecting themselves, the authors of the guidance document emphasize that these recommendations should complement, not replace, those issued by the Centers for Disease Control and Prevention (CDC) and local and institutional authorities.
Despite a low overall case fatality rate (2.3%) associated with COVID-19 infection, mortality rates are higher among elderly patients (14.8% in patients aged ≥80 years in China) and among patients with cardiovascular disease, diabetes, and hypertension (10.5%, 7.3%, and 6.0%, respectively).2
Acute Cardiac Complications
According to a case report of 138 patients hospitalized for COVID-19 infection, 16.7% and 7.2% later developed arrhythmia and acute cardiac injury, respectively.3 Other reports indicate the occurrence of cardiovascular conditions, including cardiac arrest, myocardial infarction, acute-onset heart failure, and myocarditis, in patients with COVID-19.
It is recommended that cardiologists be prepared to support their colleagues in managing patients with cardiac complications who are severely affected by the virus. In addition, they are urged to guide critical care teams providing extracorporeal circulatory support to patients with COVID-19 (ie, for the use of veno-venous vs veno-arterial extracorporeal membrane oxygenation). Patients with electrocardiogram changes, cardiomegaly, arrhythmia, or heart failure should be given echocardiography.
Care for Patients With Cardiovascular Conditions
Given the worse COVID-19 prognosis in patients with vs without cardiovascular conditions, it is critical that these individuals be identified promptly. Cardiologists are encouraged to advise patients with cardiovascular conditions on the importance of following precautions issued by the CDC to avoid COVID-19 infection, as well as to ensure their immunization status, particularly against Streptococcus pneumoniae and influenza. Cardiologists located in areas with declared COVID-19 cases should consider replacing in-office with telehealth visits for their patients with a stabilized condition. Patients with COVID-19 and a cardiovascular condition, among other comorbidities, may be prioritized for treatment.
Cardiologists should look out for symptoms of acute myocardial infarction, as in the COVID-19 context, this condition may not be detected. Caution should be used when administering fluids to manage viral infections in patients with volume overload conditions or heart failure.
Cardiovascular healthcare professionals in areas with COVID-19 outbreaks should ensure the use of personal protection measures, in addition to common precautions used to mitigate the transmission of infectious diseases.
The document’s authors recommend that cardiovascular teams develop detailed protocols, in accordance with plans for infectious disease response used at their institution, to diagnose, triage, isolate, and manage patients with COVID-19 and a comorbid cardiovascular condition. Cardiovascular teams are encouraged to rehearse these protocols and to use personal protective equipment, according to CDC guidelines.
Protocols specific to patients with acute myocardial infarction, with or without COVID-19, should be developed in an effort to keep the use of catheterization laboratory and the involvement of medical personnel to a minimum (ie, with the use of percutaneous coronary intervention and coronary artery bypass grafting). In addition, requirements for enhanced personal protection should be predetermined, and postprocedural sterilization sufficiency assessed.
1. American College of Cardiology. COVID-19 clinical guidance for the cardiovascular care team. https://www.acc.org/~/media/665AFA1E710B4B3293138D14BE8D1213.pdf. Updated March 6, 2020. Accessed March 9, 2020.
2. Zhi ZLXBXA. The epidemiological characteristics of an outbreak of 2019 novel coronavirus disease (COVID-19) [in Chinese]. 2020;41(2):45-151.
3. Wang D, Hu B, Hu C, et al. Clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus-infected Pneumonia in Wuhan, China [published online February 7, 2020]. JAMA. doi:10.1001/jama.2020.1585