- Severe acute respiratory syndrome coronavirus 2 (SARS-CoV‑2) causing coronavirus disease 2019 (COVID-19) has reached pandemic levels;
- Patients with cardiovascular (CV) risk factors and established cardiovascular disease (CVD) represent a vulnerable population when suffering from COVID-19;
- Patients with cardiac injury in the context of COVID-19 have an increased risk of morbidity and mortality.
The SARS-CoV‑2 causing COVID-19 has reached pandemic levels since March 2020. In the absence of vaccines or curative medical treatment, COVID-19 exerts an unprecedented global impact on public health and health care delivery. Owing to the unexpected need for large capacities of intensive care unit (ICU) beds with the ability to provide respiratory support and mechanical ventilation, temporary redistribution and reorganization of resources within hospitals have become necessary with relevant consequences for all medical specialties. In addition, protective measures against SARS-CoV‑2 gain particular significance for health care personnel (HCP) in direct contact with patients suffering from COVID-19 as well as for ambulatory and hospitalized patients without infection. In view of finite health care resources, health care providers are confronted with ethical considerations on how to prioritize access to care for individual patients as well as providing care for COVID-19 while not neglecting other life-threatening emergencies. Of note, assays to detect the virus in asymptomatic and symptomatic patients have important limitations in terms of sensitivity and specificity and will be complemented by tests for antibodies to identify those that already have been infected previously.
SARS-CoV‑2 not only causes viral pneumonia but has major implications for the CV system. Patients with CV risk factors including male sex, advanced age, diabetes, hypertension and obesity as well as patients with established CV and cerebrovascular disease have been identified as particularly vulnerable populations with increased morbidity and mortality when suffering from COVID-19. Moreover, a considerable proportion of patients may develop cardiac injury in the context of COVID-19 which portends an increased risk of in-hospital mortality. Aside from arterial and venous thrombotic complications presenting as acute coronary syndromes (ACS) and venous thromboembolism (VTE), myocarditis plays an important role in patients with acute heart failure (HF). Moreover, a wide range of arrhythmias has been reported to complicate the course of COVID-19 including potential pro-arrhythmic effects of medical treatment targeted at COVID-19 and associated diseases. Owing to redistribution of health care resources, access to emergency treatment including reperfusion therapy may be affected depending on the severity of the epidemic at a local level. This is further aggravated by increasing concerns of delayed presentation of CV emergencies as patients are afraid to seek medical attention during the pandemic.
For all these reasons, the European Society of Cardiology (ESC) has assembled a group of experts and practitioners with experience in the care of COVID-19 patients to provide a guidance document relevant for all aspects of CV care during the COVID-19 pandemic. While the document is comprehensive, it is important to point the reader to what the document is unable to do and what the limitations are:
- The document is not a guideline but rather a guidance document. The recommendations are the result of observations and personal experience from health care providers at the forefront of the COVID-19 pandemic. Current evidence related to SARS-CoV‑2 and its disease manifestations is observational and prospectively designed interventions are missing to form the basis for evidence-based recommendations;
- This guidance document does not replace any of the official ESC guidelines and is valid only as long as the pandemic status is maintained by the World Health Organization (WHO);
- This guidance document does not override the individual responsibility of health professionals to make appropriate decisions in the circumstances of the individual patients, and the final decisions concerning an individual patient must be made by the physician(s) responsible;
- The guidance provided in the document should in no way interfere with recommendations provided by local and national health care authorities;
- The pandemic represents a moving target with peak and plateau reached at various timepoints in different regions worldwide. Accordingly, some aspects discussed in this document may only apply to regions most heavily affected by the COVID-19 pandemic, whereas other criteria may apply to less affected geographies;
- The document provides only a snapshot with preliminary information that may change and mature over time with increasing knowledge, evidence from prospective studies and changes in the pandemic. Therefore, comments may be placed on the website that may be considered by the authors for future updates;
- Currently there is no evidence-based treatment of COVID-19 infections and experimental treatment may have cardiac side-effects. We encourage experimental treatments to be part of controlled trials whenever possible.
2.1. Impact of Cardiovascular Comorbidities on COVID-19 Infection Outcomes
- CV comorbidities are common in patients with COVID-19 infection;
- Presence of CVD is associated with increased mortality in COVID-19 infections;
- CVD risk factors and disease correlate with increasing age
By 10 March 2020, 4296 persons world-wide had died from COVID-19 infection. By 7 May, 3.67 million had tested positive and more than 250 000 had died.1 The overall case-fatality rate is very country-specific for COVID-19 infection and depending on the phase of the epidemic, testing, registration, demography, healthcare capacity and governmental decisions.2
For most countries, it is uncertain how the registration is organized which makes the comparison of case-fatality rates between countries difficult. The excess death rate is a more reliable approach to compare the impact of the COVID-19 pandemic in different countries. An article in the New York Times demonstrated that there are large differences in the excess date rates. Germany has only an excess death rate of 4% which is surprisingly low in comparison with other countries or cities such as Italy (49%), the United Kingdom (65%) (UK), Spain (67%) or New York City (297%).3
Furthermore, COVID-19 infection has similar infection rates in both sexes; however, mortality rates are higher in men.4 Daily situation reports of the COVID-19 pandemic are disseminated by the WHO on their website.
After the start of the COVID-19 pandemic in Wuhan, China, the epicenter of the epidemic is now in Europe. Figure 1 gives an overview of the evolution of laboratory-confirmed cases of COVID-19 in Europe.
A large Chinese study analyzed 72 314 patient records which consisted of 44 672 (61.8%) confirmed cases, 16 186 (22.4%) suspected cases, and 889 (1.2%) asymptomatic cases.4 Among confirmed cases in this study, 12.8% had hypertension, 5.3% diabetes and 4.2% CVD.4 Strikingly, these numbers are lower than the prevalence of CVD risk factor in a typical Chinese population, but it is important to mention that these are not age-adjusted and 53% of cases had missing data on comorbidities.5 A study including 5700 patients from New York City, Long Island, and Westchester County (United States of America (USA)) reported a similar message that hypertension (56.6%), obesity (41.7%), diabetes (33.8%), coronary artery disease (11.1%) and congestive heart failure (6.9%) were the most common comorbidities.6 In comparison, the prevalence of hypertension, obesity and diabetes in the general population in the USA is respectively 45%, 42.4% and 10.5%.7-9 In early retrospective analysis based on data from 138 patients in Wuhan, China, approximately 50% of patients with COVID-19 infection had one or more comorbidities.10 Moreover, in patients admitted with a severe COVID-19 infection this proportion was as high as 72%.10 It remains vague whether diabetes, hypertension and CVD are causally linked or associated due to age.6 However, an important message is the fact that patients who develop severe disease are more likely to be vulnerable because of comorbid disease, including CVD.
Ethnicity seems to be linked to susceptibility and outcomes of a COVID-19 infection.11, 12 Data from the United Kingdom show that one third of patients admitted to an intensive care unit due to COVID-19 infection were from an ethnic minority background.11, 13 Reports from the USA reveal the same message that ethnic minority groups have also been disproportionately affected by COVID-19 infections.12 There are multiple potential mechanisms such socioeconomic, cultural, or lifestyle factors and genetic predisposition. Also, pathophysiological differences in susceptibility or response to infection such as increased risk of admission for acute respiratory tract,14 an increased prevalence of vitamin D deficiency,15 increased inflammatory burden, and higher prevalence of cardiovascular risk factors such as insulin resistance and obesity than in white populations.11, 16
Verity et al.17 estimated that the case fatality ratio in China (adjusted for demography) was 1.38% but estimated case-fatality depends very much on the testing strategy of non-severe cases as many cases remain unverified. Case-fatality is highest in older age groups: The case fatality ratio was 0.32 in patients aged < 60 years of age in comparison with 6.4% in patients aged > 60 years.17 In Italy case fatality ranged from 0% below age 30 years to 3.5% for age 60–69 years and 20% above age 80 years.18 Higher mortality of a COVID-19 infection in older age groups was also revealed in an American dataset.6 This underlines the fact that increasing age is an important risk factor for severe course of COVID-19 infections. Underlying CVD is also associated with higher risk for a severe COVID-19 infection. In a retrospective cohort study of 72 314 cases in China19 patients with CV comorbidities had fivefold higher mortality risk (10.5%), however, without age adjustment. Multinational cohort analyses will give more insights in the prevalence and risk of CV comorbidities in COVID-19 infection. There are several potential mechanisms explaining why the course of the disease is more severe in patients with underlying CV risk factors and CVD.20 These are described in sections 3 and 9.
2.2. Cardiovascular Manifestations and Clinical Course of COVID-19 Infection
- Severe COVID-19 infection is associated with myocardial damage and cardiac arrhythmia;
- Monitoring of cardiac toxicity of antiviral drugs is recommended.
Preceding coronaviruses outbreaks such as severe acute respiratory syndrome (SARS) and Middle East respiratory syndrome (MERS) were associated with a significant burden of CV comorbidities and complications.20,21 Common cardiac complications in SARS were hypotension, myocarditis, arrhythmias, and sudden cardiac death (SCD).22,23 Diagnostic workup during SARS infection revealed electrocardiographic changes, sub-clinical left ventricular (LV) diastolic impairment and troponin elevation. MERS was associated with myocarditis and HF.22
COVID-19 infection seems to have comparable cardiac manifestations. Autopsies of patients with COVID-19 infection revealed infiltration of the myocardium by interstitial mononuclear inflammatory cells.24 COVID-19 infections are associated with increased cardiac biomarkers levels due to myocardial injury.24-26 The myocardial injury and the increased levels of biomarkers are likely associated with infection-induced myocarditis and ischaemia.27 In a study by Shi et al.26 in 416 patients of whom 57 died, cardiac injury was a common finding (19.7%). In the patients who died, 10.6% had coronary artery disease (CAD), 4.1% had HF, and 5.3% had cerebrovascular disease.26 Moreover, in multivariable adjusted models, cardiac injury was significantly and independently associated with mortality (hazard ratio [HR]: 4.26).26 Similarly, in a study by Guo et al.25, elevated troponin T levels due to cardiac injury was associated with significantly higher mortality. These patients were more likely to be men, to be older and to have more comorbidities such as hypertension, coronary heart disease.25 Severe COVID-19 infections are also potentially associated with cardiac arrhythmias at least in part due to infection-related myocarditis.10
Next to acute complications, COVID-19 infection may also be linked with an elevated long-term CV risk. It is well established that in patients with pneumonia, hypercoagulability and systemic inflammatory activity can persist for a long period.2,20 Moreover, follow-up studies of the SARS epidemic demonstrated that patients with a history of SARS-coronavirus infection often had hyperlipidaemia, CV system abnormalities or glucose metabolism disorders.20-22 However, SARS was treated with pulses of methylprednisolone which could be the explanation for the long-term perturbation of lipid metabolism rather than a consequence of the infection itself.24 Naturally, no long term effects of a COVID-19 infection are known yet but these effects of a SARS-coronavirus infection justify surveillance of recovered COVID-19 infection patients.
3. Pathophysiology - Mechanism of Disease in Relation with the Cardiovascular System
- The pathobiology of coronavirus infection involves SARS-CoV‑2 binding to the host receptor angiotensin-converting enzyme 2 (ACE2) to mediate entry into cells;
- ACE2, which is expressed in the lungs, heart and vessels, is a key member of the renin angiotensin system (RAS) important in the pathophysiology of CVD;
- CVD associated with COVID-19, likely involves dysregulation of the RAS/ACE2 system due to SARS-CoV‑2 infection and due to comorbidities, such as hypertension;
- CVD may be a primary phenomenon in COVID-19, but may be secondary to acute lung injury, which leads to increased cardiac workload, potentially problematic in patients with pre existing HF;
- Cytokine release storm, originating from imbalance of T cell activation with dysregulated release of interleukin (IL)-6, IL-17 and other cytokines, may contribute to CVD in COVID-19. IL-6 targeting is being tested therapeutically;
- Immune system activation along with immunometabolism alterations may result in plaque instability, contributing to development of acute coronary events.
COVID-19 is caused by a novel betacoronavirus officially named by the WHO as SARS-CoV‑2. Coronaviruses are enveloped, single-stranded ribonucleic acid (RNA) viruses with surface projections that correspond to surface spike proteins.28 The natural reservoir of SARS-CoV‑2 seems to be the chrysanthemum bat,29 but the intermediate host remains unclear. SARS-CoV‑2 is highly virulent and the transmission capacity is greater than the previous SARS virus (outbreak in 2003), with high abundance in infected people (up to a billion RNA copies/mL of sputum) and long-term stability on contaminated surfaces.30 SARS-CoV‑2 is more stable on plastic and stainless steel than on copper and cardboard, and viable virus has been detected for up to 72 hours after application to these surfaces.30 While the infectivity of SARS-CoV‑2 is greater than that of influenza or SARS-coronavirus, more data are needed for accurate assessment.31 Transmission occurs primarily by a combination of spread by droplet, and direct and indirect contact, and may possibly be airborne as well. The viral incubation period is 2–14 days, (mostly 3–7 days).32 It is contagious during the latency period. SARS-CoV‑2 can initially be detected 1–2 days prior to onset of upper respiratory tract symptoms. Mild cases were found to have an early viral clearance, with 90% of these patients repeatedly testing negative on reverse transcriptase polymerase chain reaction (RT-PCR) by day 10 post-onset. By contrast, all severe cases still tested positive at or beyond day 10 post-onset.33 Median duration of viral shedding was 20 days (interquartile range: 17–24) in survivors.34 The longest observed duration of viral shedding in survivors was 37 days.34
The host receptor through which SARS-CoV‑2 enters cells to trigger infection is ACE2 (Figure 2).35,36 ACE2 is a multifunctional protein. Its primary physiological role is the enzymatic conversion of angiotensin (Ang) II to Ang-(1–7), and Ang I to Ang-(1–9), which are CV protective peptides.37 In the context of COVID-19, however, ACE2 is also involved in SARS through its function as the coronavirus receptor.38 Binding of the SARS-CoV‑2 spike protein to ACE2 facilitates virus entry into lung alveolar epithelial cells, where it is highly expressed, through processes involving cell surface associated transmembrane protein serine 2 (TMPRSS2)39 (Figure 2). Within the host cell cytoplasm, the viral genome RNA is released and replicates leading to newly formed genomic RNA, which is processed into virion-containing vesicles that fuse with the cell membrane to release the virus. SARS-CoV‑2 is spread mainly through the respiratory tract by droplets, respiratory secretions and direct contact. The RAS/ACE2 seems to be disrupted by SARS-CoV‑2 infection, which likely plays a pathogenic role in severe lung injury and respiratory failure in COVID-19.40 In addition to the lungs, ACE2 is highly expressed in human heart, vessels and gastrointestinal tract.41,42
COVID-19 is primarily a respiratory disease, but many patients also have CVD, including hypertension, acute cardiac injury and myocarditis (Figure 3 from Guzik et al.43).21,44 This may be secondary to the lung disease, since acute lung injury itself leads to increased cardiac workload and can be problematic especially in patients with pre-existing HF. CVD may also be a primary phenomenon considering the important (patho)physiological role of the RAS/ACE2 in the CV system and the fact that ACE2 is expressed in human heart, vascular cells and pericytes.45
3.1. Relationships Between Hypertension, Angiotensin-Converting Enzyme 2 and COVID-19
The prevalence of pre-existing hypertension seems to be higher in COVID-19 patients who develop severe disease versus those who do not.34,46 This seems to also be true for acute respiratory distress syndrome (ARDS) or death. These earlier studies were not age-adjusted and the impact of age still needs to be addressed. The mechanisms underlying potential relationships between hypertension and COVID-19 are thought most likely to relate confounding due to age and associated comorbidities.47 Previous speculation proposed that treatment of hypertension with RAS inhibitors may influence SARS-CoV‑2 binding to ACE2, promoting disease.48 This is based on some experimental findings that RAS inhibitors cause a compensatory increase in tissue levels of ACE2,49 and that ACE-inhibitors or ARBs may be detrimental in patients exposed to SARS-CoV-2.50 It is however important to emphasize that there is no clear evidence that using angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin receptor blockers (ARBs) lead to up-regulation of ACE2 in human tissues. The available data from blood samples suggest that there is no association between circulating levels of ACE2 and use of RAAS antagonists.51 It also appears that in experimental models ARBs may have a potentially protective influence.52,53 A recent observational study of over 8910 patients from 169 hospitals in Asia, Europe, and North America, did not show a harmful association of ACEIs or ARBs with in-hospital mortality,54 while a Wuhan study demonstrated that in 1128 hospitalized patients use of ACEI/ARB was associated with lower risk of COVID-19 infection or serious complication or deaths from COVID-19 infection.47, 54-60 The recent data are all-cause mortality compared with ACEI/ARB non-users.60 This is in line with prior guidance from major CV Societies, that stated that patients on ACEIs or ARBs should not stop their treatment.51,61
3.2. Acute Cardiac Injury and Myocarditis in COVID-19
Myocarditis appears in COVID-19 patients several days after initiation of fever. This indicates myocardial damage caused by viral infection. Mechanisms of SARS-CoV-2-induced myocardial injury may be related to upregulation of ACE2 in the heart and coronary vessels.44,61 Respiratory failure and hypoxia in COVID-19 may also cause damage to the myocardium and immune mechanisms of myocardial inflammation may be especially important.27,44,61 For example, cardiac injury leads to activation of the innate immune response with release of proinflammatory cytokines, as well as to the activation of adaptive auto-immune type mechanisms through molecular mimicry.
3.3. Immune System Dysregulation and Cardiovascular Disease in COVID-19
Inflammatory mechanisms and activation of immune responses underlie a large range of CVDs including atherosclerosis, HF and hypertension.62,63 This dysregulation may have different degrees in COVID-19. Firstly another receptor through which SARS-CoV‑2 may enter cells is cluster of differentiation 209 (CD209).64 CD209 is expressed in macrophages promoting virus invasion into immune cells in cardiac and vascular tissues. More importantly, in severe cases of COVID-19, systemic increases of numerous cytokines including IL-6 IL-2, IL-7, granulocyte colony-stimulating factor, C-X-C motif chemokine 10 (CXCL10), chemokine (C-C motif) ligand 2, and tumour necrosis factor-α have all been observed in subjects with COVID-19,65 which corresponds to the characteristics of a cytokine release syndrome (CRS). Altered vascular permeability can result in non-cardiogenic pulmonary oedema and promotes ARDS as well as multi-organ dysfunction. High serum IL-6 levels are a common feature in CRS. IL-6 is a clinical predictor of mortality in COVID-19.66 Thus IL-6 targeting may be permissive for use in COVID-19 to tackle the CRS. Finally, it has been shown that hypertension is associated with circulating lymphocytes in patients67 and CD8 T cell dysfunction with development of CVD.68 CD8 T cells are a pillar of antiviral immunity, thus their dysfunction can make the organism inefficiently target virally infected cells.
4. Strategies for Diagnosing SARS-CoV-2
- Diagnosis of COVID-19 relies on a combination of epidemiological criteria (contact within incubation period), presence of clinical symptoms as well as laboratory testing (nucleic acid amplification tests) and clinical imaging based tests;
- Antibody and SARS-CoV‑2 antigen based enzyme-linked immunosorbent assay (ELISA) tests are under development and are not yet fully validated;
- Widespread testing proves efficient in the containment phase of the epidemic;
- Quality of sample collection (deep nasal swab) and transport (time) to laboratories are essential to avoid false negative outcomes;
- Lung computed tomography (CT) imaging may be used as a diagnostic test in COVID-19.
As evidenced by previous epidemics, including SARS and MERS, highly sensitive and specific laboratory diagnostics are essential for case identification, contact tracing, animal source finding, and efficient and rational containment measures.69 Precise case identification is essential in order to isolate vulnerable individuals. Based on current epidemiological analysis, CVD conveys risk of a more severe outcome of COVID-19;21,44 therefore, testing should be particularly widely considered in CVD patients. Moreover, in similarity to influenza, efficient testing of carers and people in contact with high risk patients may allow protection of subjects with multiple comorbidities. The decision to test should be based on clinical and epidemiological factors and linked to an assessment of the likelihood of infection, in particular when availability of tests is limited. Available testing strategies are outlined below (Table 1).
While isolation of the virus itself using electron microscopy would be the most specific diagnostics, it requires biosafety level-3 facilities which are not available in most healthcare institutions. Serum antibody and antigen detection tests would be the easiest and fastest, but have not yet been validated, and there may be cross-reactivity with other coronaviruses, especially SARS-coronavirus. Furthermore, antibodies are not measurable in the initial phase of the infection. Therefore, real-time PCR remains the most useful laboratory diagnostic test for COVID-19 worldwide.
Comparative specificity and sensitivity of these tests needs to be carefully assessed, when more data is available. It is important to note that negative results of molecular testing (RT-PCR) do not preclude SARS-CoV‑2 infection and should not be used as the sole basis for patient management decisions but must be combined with clinical observations, patient history, and epidemiological information. There are a number of factors that may lead to a negative result in an infected individual. These include poor quality of the specimen (small material), collection late or very early in the infection, poor handling/shipping as well as technical reasons inherent in the test such as virus mutation or PCR inhibition. Therefore, retesting is recommended after 48 hours in clinically suspected cases that test negative.
It is essential that adequate standard operating procedures are in use and that staff are trained for appropriate specimen collection, storage, packaging, and transport. This must be observed in order for testing to be reliable and safe for staff and patients.
The optimal testing material includes nasal swab rather than pharyngeal. In order to obtain a sufficiently deep swab, the sample must be obtained by experienced and trained staff. According to a comparative study using lung CT as comparator, the sensitivity of nasopharyngeal swab may be limited to 60–70%.72 It has also been concluded that the test does not seem to change clinical decisions and diagnostic considerations in subjects with pretest probability exceeding 60–70% (e.g. subjects with positive epidemiological and clinical criteria fulfilled). This however does not indicate that such tests should not be performed to confirm infection, but it is important that the test is repeated if there is clinical suspicion of COVID-19 infection. Lung CT has a high sensitivity for diagnosis of COVID-19 in hospitalized patients who are RT-PCR positive. In a study undertaken between 06 January and 06 February 2020 in Tongji Hospital, Wuhan, China, in a population of 1014 patients – when using RT-PCR as a reference, the sensitivity of lung CT imaging for COVID-19 was 97%.72 Importantly, 60–93% of patients had initial positive lung CT consistent with COVID-19 before the initial positive RT-PCR results.
Nucleic acid shedding is also an important tool to verify patient improvement, although 42% of patients showed improvement of follow-up lung CT scans before the RT-PCR results turning negative.72 It is important, however, that nucleic acid shedding does not always indicate presence of live virus.
Widespread testing strategies included drive-through testing in South Korea. However, testing capacity may be insufficient. Thus testing priorities have been suggested by individual health systems such as one proposed by Centers for Disease Control for the United States (US) (Table 2). Sample pooling strategy has been proposed in relation to sample collection as the most cost-efficient tool for population-wide screening, for example at airports.
5. Protective Measures for Health Care Personnel and Patients in Cardiology
5.1. General Risk Assessment and Protective Measures
Taking into account that there are only a few documents regarding type and level of protection of HCP, the ESC Guidance Document considered the WHO document,73 the American Center for Disease Control and Prevention guidelines on COVID-19,74 the European Centre for Disease Control guidelines on COVID-19;75 but also Chinese data76,77 and experiences from European countries with the largest outbreaks of COVID-19. Importantly, the ESC Guidance document aims to suggest a high level of protection for HCP in the worst transmission scenario of SARS-CoV‑2 infection. Different settings, such as countries with no cases, countries with sporadic cases, countries experiencing case clusters in time, geographic location and/or common exposure should prepare to respond to different public health scenarios, recognizing that there is no one size fits all approach to managing cases and outbreaks of COVID-19. Each country should dynamically assess its risk and rapidly change the definitions according to their local situation, depending on the phase of the epidemic, demography, healthcare capacity, and governmental/local health authorities’ decisions.
5.1.1. Risk of SARS-CoV-2 Infection in Health Care Providers
In a recent report related to 138 confirmed COVID-19 cases, 41.3% were considered acquired infection from the hospital, and more than 70% of these patients were HCP.78 Health care workers are in fact at increased risk for contracting the virus, as demonstrated by Wu and colleagues, who reported that in China 1716 of the 44 672 (3.8%) infected individuals were professionals (see later).19
Generally, protection against COVID-19 needs to be differentiated according to the level of risk based on patient presentation, type of procedures and interaction and HCP risk status. Table 3 provides general recommendations.
The precautions taken depend on COVID-19 case definition as defined in Table 4.
The level of protection of HCP depends on patient risk status, setting and procedure performed (Table 5). In addition to personal protective equipment (PPE) for HCP, all suspected/probable or confirmed SARS-CoV‑2 patients should wear a disposable surgical mask when in room with HCP or other persons.
FFP3, FFP2 and N95 are designed to achieve a very close facial fit and very efficient filtration of airborne particles. Powered air-purifying respirator (PAPR) is a type of PPE consisting of a respirator in the form of a hood, which takes ambient air contaminated with pathogens, actively filters these hazards, and delivers the clean air to the user's face and mouth (Figure 4).
All HCP should be well-versed in proper techniques for donning and removing PPE including eye protection (Figure 5 and Figure 6).77
5.2.1. Ambulatory Setting
- If possible, it is advisable to provide a surgical mask to every outpatient and health care giver especially in countries experiencing community transmission;
- The facility should perform a triage to assess patient risk status (Table 4);74
- This will allow distinguishing of two types of patients, the probable/suspected case or the not probable/suspected or negative case. The first one should be managed in a dedicated ambulatory setting with HCP protection Level II, while the second one should be managed in another ambulatory with HCP protection Level I (Table 5).
5.2.2. Ward Setting
- If possible, it is advisable to provide a surgical mask to every inpatient and care giver, especially in countries experiencing community transmission;74,76,77
- Newly admitted patients in a cardiology ward should be regarded as possibly infected by SARS-CoV‑2 according to Table 4.82 In these cases, the patient should undergo a swab test and should be managed in the meantime with level II or III protections (Table 5). These patients need to be managed in a dedicated area of the ward;
- Confirmed cases should be managed with level II or III protection if possible, in airborne precaution single rooms with a dedicated bathroom. Most hospitals will however be cohorting confirmed COVID-19 patients, since there may not be enough individual isolation capacity;
- The use of dedicated medical equipment (e.g. blood pressure [BP] cuffs, stethoscopes and thermometers) for confirmed/probable/suspected COVID-19 cases is strongly recommended.75 If not possible, equipment must undergo disinfection according to local instructions;
- If the swab test is negative, but suspicion of SARS-CoV‑2 infection is maintained, it is advisable to perform either a second swab test, endotracheal aspirate and/or a lung CT scan, depending on local capabilities and symptoms, bearing in mind the limited sensitivity of swab tests. These patients should be maintained in a dedicated area of the ward, with private room and bathroom, and isolated until the result of the new test is available;65
- Other cases should be managed with level I protection (Table 5), in a "clean" area of the ward;74
- If there are sufficient resources, there is a benefit in testing patients without COVID-19 symptoms, in particular in high-prevalence areas.
5.2.3. Emergency Department
- It is advisable to provide a surgical mask to every emergency department (ED) patient, especially in countries experiencing community transmission;
- The safety of HCP in the setting of ED and ICU is a major challenge and requires detailed and dedicated training on the appropriate use of PPE;
- COVID-19 triage should be performed and dedicated areas should be identified to manage not suspected from suspected/probable cases;74
- Before performing cardiology consultations in the ED, it is advisable to carry out a quick telephone interview to assess if the patient has suspected COVID-19 symptoms or risk factors for COVID-19 (see Table 3) or suspicious chest X ray/CT scan;74
- If any suspicion is present and cardiology advice is urgent, without having the chance to postpone it until the result of the swab test, the patient should be deemed positive for SARS-CoV‑2 infection and maximum protection measures must be taken (Level II protection, Level III protection in case of aerosol generation procedure [AGP]) (Table 5);
- Other ED cases should be managed with level I protection (Table 5).
5.2.4. Intensive Care Unit
- Since patients admitted to ICU are critical and may be supported by ventilation (i.e. continuous positive airway pressure [CPAP], orotracheal intubation), a high threshold of protection should be applied to patients with confirmed/suspected/possible COVID-19, with Level II protection or Level III protection in case of AGP (Table 5);
- It is advisable that every patient has his own room and non-COVID-19 patients should be managed with Level I protection (Table 5) by dedicated HCP different from the ones who care for COVID-19 patients.76,77
5.2.5. Catheterization Laboratory
- HCP should be well-versed in proper techniques for donning and removing PPE including eye protection (Figure 5 and Figure 6).77 Catheterization laboratory directors should ensure adequate availability, replacement and training in the use of this equipment;
- All patients entering the catheterization laboratory should wear a surgical mask.
126.96.36.199. ST-Segment Elevation Myocardial Infarction
Because there is no time to wait for nasopharyngeal swab result, the procedure should be performed in a dedicated COVID-19 catheterization laboratory if available and patients should be triaged according to Table 4. In regions with high rates of community transmission, it is reasonable to regard all patients as possible SARS-CoV‑2 positive and HCP protected accordingly (Table 5)
188.8.131.52. Non-ST-Segment Elevation Myocardial Infarction – Acute Coronary Syndrome
- Very high-risk non-ST-segment elevation (NSTE)-ACS should follow the ST-segment elevation myocardial infarction (STEMI) pathway and HCP protected accordingly;
- Others should undergo a nasopharyngeal swab immediately after admission (Figure 12). Waiting for swab result, patients must be isolated in a dedicated and monitored ED area because of the prevalence of asymptomatic patients with SARS-CoV‑2 infection, with the aim to reduce the risk of infection spreading within the hospital. When there are two negative results within 48 hours and absence of suspicious symptoms of virus infection, coronary angiography and eventual percutaneous coronary intervention (PCI) may be performed in a catheterization laboratory reserved for SARS-CoV‑2-negative patients.
- Patients with SARS-CoV‑2 positive test
- If an invasive approach is clinically indicated, the procedure should be performed in a dedicated COVID-19 catheterization laboratory if available;
- Intubation threshold should be lowered in patients with borderline respiratory status to avoid emergent intubation and aerosol generation in the catheterization laboratory;
- Because patient transportation from the ward to the catheterization laboratory may carry the risk of in-hospital infection transmission, some procedures routinely performed in the catheterization laboratory (e.g. Swan-Ganz catheter placement, pericardiocentesis, and intra-aortic balloon pump insertion) should be considered for bedside performance;
- The catheterization laboratory staff should be minimized and, in case of haemodynamic instability of the patient, should wear Level II or Level III PPE (Table 5), including gown, gloves, goggles (or shields), and a FFP2/FFP3 mask (Figure 4);
- Any intubation, suction, or cardiopulmonary resuscitation (CPR) may cause aerosol dispersion of respiratory secretions with increased likelihood of exposure to the staff. For this reason, use of powered air-purifying respirator (PAPR) systems, if available, may be reasonable (Figure 4);
- In case of manual ventilation during CPR, a high-efficiency particulate air filter may be placed between the tube and the bag valve mask to reduce the risk of aerosol dispersion;
- Because most catheterization laboratories are not designed for infection isolation with negative pressure, a terminal cleaning and sanitization should be performed after each procedure. Of note, air exchange times of the catheterization laboratory should be checked (minimum 15 exchanges per hour, ideally 30 exchanges per hour).
5.2.6. Electrophysiology Laboratory
Most of the electrophysiology (EP) activity is being markedly reduced or suspended in areas that have been severely affected by COVID-19 outbreak. Residual EP activity should be maintained for selected categories of patients (Table 7 and Table 13).
Protection of the HCP:83
- EP laboratories exclusively dedicated to patients potentially infected with SARS-CoV‑2 are not readily available in most institutions but should be exploited whenever possible;
- All patients with clinical indication for an EP procedure should undergo a nasopharyngeal swab immediately after admission;
- In case of haemodynamic instability and possible COVID-19 case (Table 3), the procedure should be performed with Level II protection measures (Table 5).
- In critical conditions such as syncope and complete atrioventricular (AV) block, patients should immediately be transferred to the EP laboratory and undergo pacemaker (PM) implantation under Level II protection measures (Table 5). After the procedure, these patients should be transferred to a dedicated COVID-19 area until screening for possible SARS-CoV‑2 infection is performed;
- In case of two negative results within 48 hours and absence of suspicious symptoms of COVID-19 infection, the planned procedure may be performed using standard protective tools;
- Patients with SARS-CoV‑2 positive test:
- In haemodynamic stability, ablation procedures should be deferred using intravenous (i.v.) antiarrhythmic drugs (AADs) as indicated by the underlying arrhythmia;
- Patient access to and departure from a "joint" EP laboratory should be operated using the pertinent internal paths;
- The number of operators should be limited to the essential. Ideally, one nurse, one operator, one assistant at the console and one anaesthesiologist, when indicated;
- No specific instructions are due with regard to the type of implant techniques and implantable devices that, however, should have remote control technology;
- Cleaning and sanitization of the EP laboratory should be performed after each procedure.
5.2.7. Transesophageal Echocardiography, Continuous Positive Airway Pressure and Orotracheal Intubation Patients
The major issue is that the viral load in the airway is probably very high and very contagious.84 This poses significant risks for HCP performing non-invasive ventilation by CPAP or invasive ventilation with orotracheal intubation. Accordingly, a high level of vigilance is necessary to prevent contracting the infection when managing patients using CPAP, when intubation is performed or the transesophageal echocardiogram (TEE) probe is inserted.
- Patients undergoing TEE should be tested for SARS-CoV‑2 status;
- In case of two negative results within 48 hours and absence of suspicious symptoms of COVID-19 infection, the planned procedure may be performed using standard protective tools.
- In patients with positive SARS-CoV‑2 test or unknown status:
- A "point-of-care" focused ultrasound (POCUS) exam may be performed at the bedside in SARS-CoV-2–positive patients to avoid TEE and the associated infection risk for HCP;
- In case of invasive ventilation and CPAP, a Level III protection should be used, whereas for TEE a Level II protection may be sufficient (Table 5).
- CV patients should be always protected from the exposition to SARS-CoV‑2 infection, in particular because of the worse outcome for this patient group;
- Patients should be educated on how to protect themselves from virus contact and the information should be preferably provided in illustrative format (e.g. below Figure 7).
- Patients admitted to the ward services should stay in the hospital for the shortest time possible, minimizing both professionals and patient’s exposure to the virus;
- Enough resources should be kept active to cope with all the CV emergencies both for COVID-19-free and for infected patients;
- Any elective admittance for diagnostic or therapeutic purposes that may be postponed should not take place during the virus outbreak (complying with the purpose of not overwhelming institutions with non-urgent hospitalizations and at the same time with the obligation of not making stable CV patients unnecessarily exposed to virus infection);
- Staff members should be educated to respect barrier measures and dedicated lounge where social distancing is possible should be provided.
It is now well known that CV patients who develop a COVID-19 infection have a higher risk of poor in-hospital outcome.20 This is why it is mandatory to effectively protect them from being in contact with infected subjects whose COVID-19-related symptoms are still not evident or not specific. Wang et al reported a significant percentage of hospital-associated transmission of the virus (12.3% of all patients) in a cohort of hospitalized patients with novel coronavirus-infected pneumonia in Wuhan, China at the start of the pandemic.10 Based on this data, patients accessing the hospital for an acute cardiac disease with no signs or symptoms of viral infection should complete their diagnostic workflow in a clean area and finally access a COVID-19-free ward. All the measures to keep chronic cardiac outpatients at home as much as possible as well as to limit in-hospital stay of cardiac patients to the shortest acceptable time should be implemented. The adoption of a restrictive visitor policy is also strongly recommended.85
Elective procedures should be avoided during the current COVID-19 pandemic so as not to overload the health system or increase the risk of disease propagation. In this context, in order to minimize risk for COVID-19 transmission, the use of telemedicine is highly desirable especially for vulnerable groups, such as older patients. Additionally, telemedicine provides an opportunity for tele-consultations with different specialists and professionals, thus allowing patients to receive a comprehensive therapeutic approach without moving from home to the outpatient clinic or to the hospital. Also telerehabilitation (or home based rehabilitation with telephone contact with the rehab team) is an option for patients discharged from the hospital after an acute event. Finally telemedical follow up of HF and device patients is becoming more and more standard and may be considered. Telemedicine has been considered relevant in contributing to viral outbreak containment while preventing patient health from deteriorating because of misdiagnosed or mistreated CVDs.86
Beyond telemedicine ‘home care’ and ‘mobile clinics’ are currently proposed as a way to prevent unnecessary movement of patients towards hospitals, provided that nurses and physicians wear the appropriate PPE. This solution could prevent clinical instability of many cardiac diseases (i.e. chronic HF), assure patient adherence to long-term treatment and contribute to a ‘community-centred’ form of care that might be more advantageous than a purely ‘patient-centred’ care model, where only infected, hospitalized patients consume most of the available resources of the healthcare system.87
When CV patients temporarily access the hospital facilities for diagnostic or therapeutic reasons they should always protect themselves by systematically wearing surgical masks, practicing social distancing and appropriate washing/cleaning their hands with alcoholic solutions, which should be provided by the hospital staff.88 Patients should also be protected by HCP donning surgical masks, depending on the local community prevalence of COVID-19.
6. Triage Systems (Reorganization and Redistribution)
6.1. Overriding Principles of Triage
- The high priority given to patients with COVID-19 infection may compromise the rapid triage of non-COVID-19 patients with CVD;
- A proper patient triage favours the right in-hospital allocation based on the infective status and allows the prompt adoption of protective measures both by HCP and by patients;
- Acute cardiac patients accessing the intensive cardiac care unit (ICCU) or the catheterization laboratory in a fast track fashion should be considered as likely SARS-CoV‑2 positive, until they are proved not infected.
Patient triage is of paramount importance when medical services are overwhelmed by a pandemic and healthcare resources are limited. This is particularly true for the COVID-19 epidemic, whose outbreak is currently seriously challenging the healthcare systems across the world. Some peculiar aspects of this pandemic, potentially affecting triage of cardiac patients, should be outlined:
- Initial symptoms of a COVID-19 infection such as breathlessness, chest pain, or asthenia may mimic the early manifestations of a cardiac disease and therefore require a tight collaboration of different professionals and specialists, in order to assign any single patient to the correct diagnostic work up process as soon as possible. Also, COVID-19 patients might abruptly develop acute cardiac complications (such as ACS or pulmonary embolism [PE])89 and come to the hospital for this reason. In this case a prompt management of both diseases could also contribute to a better outcome;
- In each institution, an explicit diagnostic algorithm for suspected COVID-19 infection is important to inform triage. Patients with possible/probable or confirmed COVID-19 infection (Table 4) should be triaged as COVID-19 infected;
- In particular, critically ill patients for acute CV condition (STEMI patients, out-of-hospital cardiac arrest [OHCA] patients), should quickly access medical or interventional treatment according to the current evidence-based guideline recommendations. Therefore, they should be presumed as SARS-CoV-2 positive, until proven otherwise. Accordingly, HCP should wear adequate PPE, particularly in the triage phase (Table 4). Recommendations made by the WHO state that contact precautions (by means of appropriate face masks, eye glasses, hydro repellent lab coats and gloves) are necessary since the very early triage phase.
- Physicians should triage cardiac patients requiring a highly intensive level of care who have a concomitant suspected or confirmed COVID-19 infection based on local protocols that take into consideration ethical issues and resource availability.90
6.2. Hospital and Ambulance Networks
- A contained number of hospitals equipped with a catheterization laboratory operating 24 hours/7 days should still maintain their hub role for the management of time-dependent acute CVD;
- Resources and cardiac specialists should be concentrated in the hub centres to guarantee the appropriate acute treatment to all the cardiac patients in need of it;
- The ambulance networks should be rearranged according to the new hub and spoke organization.
Hub centres are committed to provide acute reperfusion to all patients requiring an urgent PCI. Patients with STEMI or high-risk NSTEMI should be triaged by the emergency medical services team and timely transported to hub centres, if feasible. As a general rule we recommend that the number of catheterization laboratories available for primary PCI should not be reduced during the pandemic, to avoid an increase in door-to-balloon time, to diminish the risk of infection during transfer for both professionals and/or patients, and to unload the health care system. Regional STEMI networks should adapt to dynamic changes of the pandemic in every region according to local medical and logistic resources. As an example, in Lombardy, Italy, a system of specialized COVID-19 referral hospitals has been defined at the start of the virus epidemic, reducing by more than 60% the number of previous referral centres with 24 hour/7 day capacity to perform a primary PCI.91 Active shifts have been also assigned to interventional cardiologists, in order to satisfy the foreseen increased number of STEMI or NSTEMI patients arriving at the hospital.92
The ambulance networks also need to be reorganized in order to bring the patients straight to the COVID-19 referral hospital, skipping the spoke centres from where a secondary transportation could be difficult to arrange and time-consuming. The major objective of this rearrangement is primarily to allow for a timely treatment of the acute CVD, despite the unavoidable epidemic-related delays. It is also functional to secure patients to COVID-19-dedicated hospitals or to hospitals with isolated COVID-19 dedicated facilities when patients with acute CVDs are highly suspect for COVID-19 infection. China has been the first country to receive specific recommendations for a transport work programme directly by the country Health Authorities.93
6.3. Emergency Department
- A rearrangement of the ED is mandatory to separate suspected COVID-19 patients from patients without SARS-CoV‑2 infection;
- Local protocols to rapidly triage patients with respiratory symptoms should be available as well as facilities where patients wait for the results of COVID-19 screening tests. Patients with mild, stable diseases should be promptly discharged.
In countries highly affected by the COVID-19 pandemic EDs have been re-organized to provide possible COVID-19 patients with dedicated access areas and isolated facilities from their first arrival to the hospital. Local protocols for rapidly triaging patients with respiratory symptoms should be issued with the aim of differentiating patients with CVDs from COVID-19 patients. In China for example patients with no geographical or family history of virus infection, fever, respiratory symptoms, fatigue or diarrhoea were considered ‘COVID-19 unlikely’ and their CVD was usually treated with standard protocols.94 A check-list should be adopted to quickly differentiate patients with possible or probable COVID-19 infection from non-infected patients (Table 3 and Table 4). Patients with mild, stable diseases should be discharged from the ED as soon as possible (Figure 8), with the suggestion to stay at home in quarantine if a COVID-19 infection is suspected or confirmed.
Conversely, patients in need of hospital admission for acute CVD with concomitant possible/probable SARS-CoV‑2 infection (Table 4) should rapidly undergo testing and be managed as SARS-CoV-2 infected until they have two negative tests within 48 hours. Patients in need of hospital admission not suspected of SARS-CoV‑2 infection can be managed according to standard of care.
6.4. Intensive Care Unit and Intermediate Care Unit
- Non-COVID-19 patients with acute CVDs should be preferably admitted to COVID-19 free ICUs/ICCUs, mostly available in the COVID-19 referral centres;
- Care of COVID-19 patients with severe CVDs might be downgraded to lower intensity levels, if the patient prognosis is poor and ICU/ICCU beds are in short supply.
ICU beds are mainly devoted to complicated COVID-19 patients in need of intensive care, who frequently present with underlying CVD and poor prognosis.19,95 Provided that in a pandemic situation the ethical value of maximizing benefits is recognized as the most relevant to drive resource allocation,96 this might invariably disadvantage patients with advanced age and more severe CVD who will not be prioritized for advanced care provision.
Acute CV patients who tested negative (and without clinical suspicion for) COVID-19 infection, should be accurately identified and admitted, if feasible, to dedicated areas ICUs or ICCUs free from COVID-19 patients (‘clean’ ICUs or ICCUs), particularly in COVID-19 referral hospitals. If a fully ‘clean’ facility is not available, because of overwhelming numbers of COVID-19 patients, it should be guaranteed that airborne isolation rooms are set up in the facility, effectively separating patients with COVID-19 infection from all the others to minimize their infective risk. Such organization should also allow for adequate protection of HCP and well-defined pathways to and from the isolated rooms, in order to contain the spread of infection.97
Intermediate care units (also identifiable as ICCUs level II or I according to the Association for Acute Cardiovascular Care position paper98) share the same problems of ICUs, being usually equipped with CPAP machines for non-invasive ventilation. The same solutions already discussed for ICUs are therefore also applicable to intermediate care units. Triaging CV patients in need of CPAP from COVID-19 patients with pneumonia is mandatory, but still isolated rooms for COVID-19 positive CV patients (with acute HF for example) different from rooms for COVID-19 negative CV patients are very much needed.
7. Diagnosis of Cardiovascular Conditions in COVID-19 Patients
7.1. Clinical Presentation
7.1.1. Chest Pain
- Chest pain and breathlessness is a frequent symptom in COVID-19 infection;
- Chronic and acute coronary syndrome presentations can be associated with respiratory symptoms.
The symptom of chest pain or tightness is common in patients with active COVID-19 infection. It is usually poorly localized and may be associated with breathlessness due to the underlying pneumonia. Associated profound hypoxaemia together with tachycardia may result in chest pain and electrocardiographic changes suggestive of myocardial ischaemia. Where biomarkers are altered, Type 2 myocardial infarction (MI) may be suggested. Patients with ACS do, however, experience the more typical symptoms related to ischaemia. The presence of a COVID-19 infection can make the differential diagnosis more difficult, as shortness of breath and respiratory symptoms may be present and may precede or precipitate cardiac signs and symptoms.
7.1.2. Dyspnoea, Cough, Respiratory distress
- COVID-19 patients may present with cough, dyspnoea, and ARDS
Dyspnoea (shortness of breath) is one of the typical symptoms in COVID-19. Of 1099 adult inpatients and outpatients in China, 18.7% presented with dyspnoea.80 With increasing disease severity, the proportion of dyspnoea significantly increases (31–55% in hospitalized patients and up to 92% of patients admitted to ICUs).10,65
Cough is present in 59.4–81.1% of patients with COVID-19, irrespective of disease severity.34,99 Unproductive (dry) cough is more frequent, whereas sputum production is present in 23.0–33.7%.10,34,65,80
184.108.40.206. Acute Respiratory Distress Syndrome
ARDS is characterized by bilateral opacifications on chest imaging (e.g. bilateral ground glass opacifications on CT) and hypoxaemia that cannot be explained by other causes.100 Among 1099 adult inpatients and outpatients in China, ARDS occurred in 3.4%,80 but in hospitalized patients, the rates are significantly higher (19.6–41.8%).10,34,99 The median time from disease onset to ARDS is 8–12.5 days.65 The risk of ARDS increases with older age (≥ 65 years old), presence of comorbidities (hypertension, diabetes), neutrophilia, lymphocytopenia, elevated laboratory markers of organ dysfunction (e.g. lactate dehydrogenase [LDH]), inflammation (C reactive protein) and D-dimer.99 Mortality of patients treated for ARDS in COVID-19 is high (e.g. 52–53%).10,34,65,66,80,99,100
7.1.3. Cardiogenic Shock
- In COVID-19 patients with impaired end-organ perfusion at risk of cardiogenic shock (CS) (e.g. large acute myocardial infarction [AMI]), consider also sepsis as possible or mixed aetiology;
- Myocarditis should be considered as precipitating cause of CS.
An early, accurate, and rapid diagnosis of CS in patients with confirmed or suspected COVID-19 is essential.101 The exact incidence of CS in these patients is unknown. However, the median duration between onset of symptoms and admission to ICU in critically ill COVID-19 patients has been 9–10 days, suggesting a gradual respiratory deterioration in most patients.102 A simple, actionable classification scheme for CS diagnosis has recently been proposed.103
In critically ill COVID-19 patients at risk for CS (such as those with large AMI, acute decompensated HF; Society for Cardiovascular Angiography and Interventions stage A)103 and sepsis, a mixed aetiology of CS and septic shock should be considered in addition to the sole cardiogenic component. Parameters allowing for a differential diagnosis between CS and septic shock, such as the presence of vasodilatation and central venous oxygen saturation values may be assessed. In selected cases, such as in patients with unclear reasons for haemodynamic deterioration, invasive haemodynamic monitoring via a pulmonary artery catheter may provide useful information.
The diagnostic work-up of critically ill patients with confirmed or suspected COVID-19 infection requires specific considerations:
- The proper level and type of monitoring, in addition to the haemodynamic status of the patient, should depend upon available local resources. Importantly, key diagnostic testing in patients with suspected CS, including electrocardiogram (ECG), bedside echocardiography, and urgent/emergent coronary angiography, should be integrated into local diagnostic protocols (with dedicated and/or protected equipment whenever possible) to ensure both the best deliverable care and a minimal risk of viral transmission to other patients and health care providers;
- Anecdotal clinical experience44,104 and experimental evidence indicating that > 7.5% myocardial cells have positive ACE2 receptor expression,42 the target through which SARS-CoV‑2 invades human cells, suggest that myocarditis may complicate COVID-19. This diagnosis should be considered as a potential cause of CS.
7.1.4. Out-of-Hospital Cardiac Arrest, Pulseless Electric Activity, Sudden Cardiac Death, Tachyarrhythmias, Bradyarrhythmias
- Symptoms of brady- and tachyarrhythmias do not differ from the usual clinical presentation;
- In the context of the SARS-CoV‑2 pandemic, HCP remain alert for symptoms suggestive of brady- or tachyarrhythmias as patients are still at risk of conduction disturbances and supraventricular/ventricular arrhythmias;
- Healthcare authorities and hospital managers should ensure that there is a proper pathway for the early detection and management of rhythm disorders.
There is very limited literature available on the occurrence of arrhythmia in the context of an infection by the SARS-CoV‑2 virus. In a study of 138 hospitalized patients with COVID-19 in Wuhan, arrhythmia was reported in 16.7% of total patients and in 16 of 36 patients admitted to the ICU (44%), although the authors did not further specify its type.10 In a subsequent publication from the same institution, ventricular tachycardia (VT)/ventricular fibrillation (VF) was reported as a complication of the COVID-19 disease in 11 of 187 patients (5.9%), with a significantly higher incidence in patients with elevated troponin T.25 However, the largest observational study from China, with 1099 patients from 552 hospitals, did not report any arrhythmia.80 Hypoxaemia and a systemic hyperinflammation status may lead to new-onset atrial fibrillation (AF), although there are no published data so far. However, important consideration should be given to rhythm management (drug interactions with COVID-19 treatment) and anticoagulation.
The clinical presentation of brady- or tachyarrhythmias in the context of COVID-19 does not differ from those previously described (i.e. palpitations, dyspnoea, dizziness, chest pain, syncope, etc.). However, there are concerns that in areas where the epidemic is extended, hospitals have experienced a significant decrease in emergency consultations for cardiac. Whether the underlying reason is concern for in-hospital contagion, a result of self-isolation measures or a saturation of the EDs and ambulances needs to be explored.
7.1.5. Hospitalization for Pneumonia and Time Course of Increased Subsequent Risk of Cardiovascular Death
- Pneumonia, influenza and SARS are well known to be associated with a markedly increased short-term risk for subsequent CV events, such as ACS;
- There needs to be a high alertness for CV events, such as ACS and thromboembolic events, in the short-term after pneumonia and a careful risk management approach in individuals with pre-existing CVD
Pneumonia and severe influenza infections have been associated with a markedly increased short term risk of MI and subsequent mortality, that is more common among patients at older age, nursing home resident, and patients with history of HF, coronary disease or hypertension.105-108 Moreover, for influenza epidemics it has been demonstrated that there is a consistent rise in autopsy-confirmed coronary deaths.109 Fatal AMIs have also been observed in the short term after coronavirus associated SARS.110
Notably, recent data from China suggest that myocardial injury during COVID-19 infection – as indicated by elevated troponin levels – represent one predictor of a higher risk of CV complications and an adverse clinical outcome.25,26 Moreover, an increased rate of thromboembolic events has been observed in the context of COVID-19 infection.
- The same ECG diagnostic criteria for cardiac conditions apply in patients affected by the SARS-CoV‑2 infection and in the general population
So far no specific ECG changes have been described in patients with SARS-CoV‑2 infection. Therefore, we have to assume that the overall minimal level of myocardial injury associated with the infection (see the following section on biomarkers) does not translate into characteristic ECG manifestations in the majority of patients, although ST-segment elevation in the setting of myocarditis have been described.61 As a consequence, the same ECG diagnostic criteria for cardiac conditions apply in patients affected by SARS-CoV‑2 infection and in the general population. Little is known about COVID-19 infection and arrhythmias. One report on 138 patients described an arrhythmia (not further specified) in 16.7% and the prevalence increased to 44.4% in the 16 patients who were admitted to the ICU.10 For considerations of arrhythmia and corrected QT interval (QTc) prolongation of COVID-19 therapies see section 10.1.
- Cardiomyocyte injury, as quantified by cardiac troponin T/I concentrations, and haemodynamic stress, as quantified by B-type natriuretic peptide (BNP) and N-terminal B type natriuretic peptide (NT-proBNP) concentrations, may occur in COVID-19 infections as in other pneumonias. The level of those biomarkers correlate with disease severity and mortality;
- Cardiac troponin T/I and BNP/NT-proBNP concentrations should be interpreted as quantitative variables;
- In patients hospitalized with COVID-19, mild elevations in cardiac troponin T/I and/or BNP/NT-proBNP concentrations are in general the result of pre-existing cardiac disease and/or the acute injury/stress related to COVID-19;
- In the absence of typical angina chest pain and/or ischaemic ECG changes, patients with mild elevations (e.g. < 2–3 times the upper limit of normal [ULN] do NOT require work-up and/or treatment for Type 1 myocardial infarction [T1MI]);
- In patients with COVID-19, as in patients with other pneumonias, it is suggested to measure cardiac troponin T/I concentrations only if the diagnosis of T1MI is being considered on clinical grounds, or in new onset LV dysfunction. Independently from diagnosis, monitoring of cardiac troponin T/I may help for the purpose of prognostication;
- D-Dimers quantify activated coagulation, a prominent feature in COVID-19. Due to the central role of endotheliitis and VTE in COVID-19, serial measurements of D-dimers may help physicians in the selection of patients for VTE-imaging and/or the use of higher than prophylactic doses of anticoagulation.
7.3.1. Biomarker Elevation Suggesting Cardiovascular Conditions in Patients with COVID-19 Infection
220.127.116.11. Cardiac Troponin I/T
COVID-19 is a viral pneumonia that may result in severe systemic inflammation and ARDS, and both conditions have profound effects on the heart.26,34,111 As a quantitative marker of cardiomyocyte injury, the concentrations of cardiac troponin I/T in a patient with COVID-19 should be seen as the combination of the presence/extent of pre-existing cardiac disease AND the acute injury related to COVID-19.34,66,89,111-113
Cohort studies from patients hospitalized with COVID-19 in China showed that 5–25% of patients had elevations in cardiac troponin T/I, and this finding was more common in patients admitted to the ICU and among those who died.24-26,66,111 Concentrations remained in the normal range in the majority of survivors. In non-survivors, troponin levels progressively increased in parallel with the severity of COVID-19 and the development of ARDS (Figure 10). 24,26,34,66,111
Mild elevations in cardiac troponin T/I concentrations (e.g. < 2–3 times the ULN), particularly in an older patient with pre-existing cardiac disease, do NOT require work-up or treatment for T1MI, unless strongly suggested by angina chest pain and/or ECG changes (Figure 11). Such mild elevations are in general well explained by the combination of possible pre-existing cardiac disease AND/OR the acute injury related to COVID-19.
Marked elevations in cardiac troponin T/I concentrations (e.g. > 5 times the ULN) may indicate the presence of shock as part of COVID-19, severe respiratory failure, tachycardia, systemic hypoxaemia, myocarditis, Takotsubo syndrome or T1MI triggered by COVID-19.26,34,89,111 In the absence of symptoms or ECG changes suggestive of T1MI, echocardiography should be considered in order to diagnose the underlying cause. Patients with symptoms and ECG changes suggestive of T1MI should be treated according to ESC-guidelines irrespective of COVID-19 status.24,66,113,114
18.104.22.168. B-Type Natriuretic Peptide/N-Terminal B-Type Natriuretic Peptide
BNP/NT-proBNP as quantitative biomarkers of haemodynamic myocardial stress and HF are frequently elevated among patients with severe inflammatory and/or respiratory illnesses.26,115-117 While experience in patients with COVID-19 is limited, very likely the experience from other pneumonias can be extrapolated to COVID-19.26,115-117
As quantitative markers of haemodynamic stress and HF, the concentrations of BNP/NT-proBNP in a patient with COVID-19 should be seen as the combination of the presence/extent of pre-existing cardiac disease AND/OR the acute haemodynamic stress related to COVID-19.26,115-117 At least to some extent, the release of BNP/NT-proBNP seems to be associated with the extent of right ventricular haemodynamic stress.
D-dimers are generated by cleavage of fibrin monomers by prothrombin and indicate the presence of thrombin formation or reflect an unspecific acute phase response from infection or inflammation. D Dimers also may indicate the presence of disseminated intravascular coagulation associated with shock.118 It is tempting to speculate that markers of activated coagulation or impaired fibrinolysis might contribute to acute myocardial injury, eventually also affecting coronary capillaries. Therefore, markers of haemostasis including activated partial thromboplastin time, prothrombin time, fibrin degradation products and D-Dimers should be monitored routinely. In particular, elevations of D-Dimers have been associated with poor outcome.84 Although the D-dimers have a lower specificity for the diagnosis of acute PE, 32–53% of patients still have a normal D-dimer and the vast majority has D dimers below 1000 ng/ml.10,34,80 Therefore, recommended diagnostic algorithms combing pre-test probability assessment and D dimer tests can be used in case of suspected acute PE.119 In particular, algorithms applying a pre-test probability dependent D-dimer threshold may yield a decent specificity.120-122
7.3.2. Potential Mechanisms Underlying the Biomarker Elevation
The potential mechanisms underlying myocardial injury in those with COVID-19 infection are not fully understood. However, in keeping with other severe inflammatory and/or respiratory illnesses, direct (‘non-coronary’) myocardial injury is most likely the cause. Myocarditis, septic shock, tachycardia, severe respiratory failure, systemic hypoxaemia, Takotsubo syndrome or T1MI triggered by COVID-19, are alternative causes. Direct myocardial involvement mediated via ACE2, cytokine storm, or hypoxia induced excessive intracellular calcium leading to cardiac myocyte apoptosis have been suggested as alternative mechanisms.2,48,123 As quantitative biomarkers of haemodynamic myocardial stress and HF, intracardiac filling pressures and end-diastolic wall stress seem to be the predominant triggers of the release of BNP/NT-proBNP.115-117
7.3.3. Which Biomarkers Should be Measured and When?
As in patients without COVID-19, cardiac troponin T/I concentrations should be measured whenever on clinical grounds T1MI is suspected.113 In patients with COVID-19, diagnostic algorithms for rapid rule out and/or rule-in of MI in patients with acute chest discomfort such as the ESC high-sensitivity cardiac troponin (hs-cTn) T/I 0/1-h algorithm can be expected to provide comparable performance characteristics as in other challenging subgroups with higher baseline concentrations such as the elderly and patients with renal dysfunction: very high safety for rule-out and high accuracy for rule-in, but reduced efficacy with a higher percentage of patients remaining in the observe zone.113,124-126 Detailed clinical assessment including chest pain characteristics, assessment of COVID-19 severity, hs-cTn T/I measurement at 3 hours, and cardiac imaging including echocardiography are the key elements for the identification of MI in this heterogeneous subgroup.113,124-126
Similarly, BNP/NT-proBNP should be measured whenever on clinical grounds HF is suspected.26,115-117 In patients who are not critically ill, rule-in cut-offs for HF maintain high positive predictive value even in patients with pneumonia.26,115-117 In contrast, currently recommended cut-offs should not be applied in critically-ill patients, as most critically-ill patients have substantial elevations in BNP/NT-proBNP, most likely due to the near-universal presence of haemodynamic stress and HF in these patients.26,115-117
It is a matter of ongoing debate whether cardiac troponin T/I should be measured as a prognostic marker in patients with COVID-19. The strong and consistent association with mortality observed in the currently available reports of patients hospitalized with COVID-19, with some evidence suggesting cardiac troponin T/I even as an independent predictor of mortality, should be seen in favour of this approach.25,26,34,111 On the other hand, at this point in time, based on three arguments we consider a more conservative approach even more appropriate.26,34,66,89,111-113 First, beyond cardiac troponin T/I other routinely available clinical and laboratory variables have also emerged as strong predictors of death in COVID-19 including older age, higher Sequential Organ Failure Assessment (SOFA) score, D dimers, IL-6 and lymphocyte count. It is unlikely that cardiac troponin T/I provides incremental value to a full model. Second, there is a recent risk of inappropriate diagnostic and therapeutic interventions triggered based in cardiac troponin T/I concentrations measured for prognostic purposes. Third, in patients with COVID-19 as well as with other pneumonias or patients with ARDS, at this point in time, no specific therapeutic intervention can be justified based on the use of cardiac troponin T/I as a prognostic marker.26,34,66,89,111-113
Therefore, routine measurements of cardiac troponin T/I and/or BNP/NT-proBNP in patients with COVID-19 given the current very limited evidence for incremental value for clinical decision-making is discouraged.
7.4. Non-Invasive Imaging
- Do not perform routine cardiac imaging in patients with suspected or confirmed COVID-19;
- Prevent contamination from patients to other patients, to imagers and imaging equipment;
- Perform imaging studies in patients with suspected or confirmed COVID-19 only if the management is likely to be impacted by imaging results;
- Re-evaluate which imaging technique is best for your patients both in terms of diagnostic yield and infectious risk for the environment;
- The imaging protocols should be kept as short as possible.
Non-urgent or elective cardiac imaging should not be performed routinely in patients with suspected or confirmed COVID-19 infection. Accordingly, non-urgent or elective exams should be postponed until the COVID-19 infection has ceased (Table 6).127,128
7.4.1. Transthoracic and Transesophageal Echocardiography
- Avoid performing transthoracic, transesophageal and stress echocardiograms in patients in which test results are unlikely to change the management strategy;
- TEE carries increased risks of spread of COVID-19 due to exposure of HCP to aerosolization of large viral load and should not be performed if an alternative imaging modality is available;
- In COVID-19 infected patients, the echocardiogram should be performed focusing solely on the acquisition of images needed to answer the clinical question in order to reduce patient contact with the machine and the HCP performing the test;
- POCUS, focused cardiac ultrasound study (FoCUS) and critical care echocardiography performed at bedside are effective options to screen for CV complications of COVID-19 infection.
Echocardiography can be performed bedside to screen for CV complications and guide treatment. POCUS, FoCUS and critical care echocardiography are probably the preferred modalities to image patients with COVID-19. Limited evidence exists for the use of lung ultrasound to differentiate ARDS (single and/or confluent vertical artefacts, small white lung regions) from HF.129 The presence of dilated right ventricle and pulmonary hypertension may indicate contrast CT to rule out PE. In COVID-19 infected patients, echocardiography should focus solely on the acquisition of images needed to answer the clinical question in order to reduce patient contact with the machine and HCP.
It should not be forgotten that the risk of infection remains in the reading rooms and therefore the material used should be also frequently sanitized.
7.4.2. Computed Tomography
- CV CT should be performed in hospitalized patients only with indications in which imaging results will likely impact management;
- CCTA may be the preferred non-invasive imaging modality to diagnose CAD since it reduces the time of exposure of patients and personnel;
- Cardiac CT may be preferred to TEE in order to rule-out left atrial appendage (LAA) and intracardiac thrombus prior to cardioversion;
- In patients with respiratory distress, chest CT is recommended to evaluate imaging features typical of COVID-19;
- Check renal function when contrast is indicated.
Cardiac CT should be performed when there is a potential impact on clinical management, including evaluation of symptomatic suspected CAD, acute symptomatic heart valve dysfunction, left ventricular assist device (LVAD) dysfunction, PE, urgent structural intervention.130 Cardiac CT is preferred to TEE to rule out the presence of intracardiac thrombus. In patients with acute chest pain and suspected obstructive CAD, CCTA is the preferred non-invasive imaging modality since it is accurate, fast and minimizes the exposure of patients. In patients with respiratory distress, lung CT is recommended to evaluate imaging features typical of COVID-19 and differentiate from other causes (HF, PE).94 However, it should not be used to screen for or as a first-line test to diagnose COVID-19 and should be reserved for hospitalized patients.131 A dedicated CT scanner for patients with suspected or confirmed COVID-19 is preferred. As in other imaging modalities, local standards for prevention of virus spread and protection of personnel should be followed.
7.4.3. Nuclear Cardiology
- Nuclear cardiology should be performed only in specific indications and when no other imaging modalities can be performed;
- The shortest duration of scan time and exposure should be used;
- Standard dose imaging with rapid protocols of data acquisition are recommended.;
- Attenuation corrected imaging should be considered;
- Positron emission tomography (PET) minimizes the acquisition times.
Many of the diagnoses can be evaluated with other imaging modalities that limit the risk of virus spread. Nuclear cardiology tests require long acquisition times and exposure of patients and personnel.132 The use of PET-CT can be limited to patients with suspected endocarditis of prosthetic valves or intracardiac devices when other imaging modalities are inconclusive or to avoid the performance of a TEE which is associated with larger risk of spreading. Single photon emission computed tomography (SPECT) or PET may also be used for diagnosing ischaemia in patients with suspected obstructive CAD when CCTA is not appropriate or available.
7.4.4. Cardiac Magnetic Resonance
- Use shortened cardiac magnetic resonance (CMR) protocols focused to address the clinical problem;
- Check renal function when contrast is indicated;
- CMR is preferred in acute myocarditis.
The risks of contamination during a CMR scan is probably similar to a CT scan, but lower than during an echocardiographic study. Only clinically urgent CMR scans should be accepted.133
Longer time exposure in the scanner will probably increase the chances of contamination of equipment and staff. In order to minimize the examination time, shortened CMR protocols focused to address the clinical problem should be used.133 A dedicated MR scanner for patients with suspected or confirmed COVID-19 is a clear advantage. Allow time for a deep cleaning after each patient with suspected or confirmed COVID-19 infection.
The role of CMR in COVID-19 patients is currently not clear. Accepted diagnostic indications for CMR should be considered as appropriate in these patients, but should not be performed unless clinically necessary and after a reconsideration of best suited imaging technique.128
Another important attention is the use of CMR contrast in patients with COVID-19. Renal function might be decreased in patients with COVID-19 and might contradict a clinically urgent CMR scan.
One indication for an acute CMR might be suspicion of acute myocarditis, which has been reported in patients with COVID-19.134 Typical symptoms might be elevated troponins, ventricular dysfunction and/or severe arrhythmias that cannot be explained by other diagnostics and imaging methods.20
7.4.5. Exercise Testing
Performance of exercise testing (either conventional, Echo or nuclear) has major limitations in the COVID-19 era. During exercise the patient increases breath rate and the amount of aerosol or droplets production, even if wearing a surgical mask (that could strongly affect his/her exercise capacity). This problem is further increased since rooms of outpatient clinics are rarely large and well aerated. Performance of exercise testing is discouraged in COVID-19 suspect or positive patients and, in general, in every patient in COVID-19 epidemic or potentially epidemic areas. Alterative diagnostic methods for CAD not requiring exercise should be used as an alternative to exercise testing whenever possible. There remain conditions where exercise testing is necessary. These mainly concern patients with heart failure. Cardiopulmonary exercise testing remains the method of choice for the assessment of exercise capacity, a well-known prognostic index, and for the indication to heart transplantation in patients with heart failure. In addition, exercise testing is proposed as the method of choice for the diagnosis of heart failure with preserved ejection fraction (HFpEF) in patients with breathlessness and intermediate scores for HFpEF diagnosis. A low-level exercise may be, however, sufficient in these cases.135
7.5. Differential Diagnosis
- The presence of COVID-19 infection should not preclude a systematic search for CV events, including ACS;
- COVID-19 infection-related injury should be kept in mind as differential diagnosis;
- Other manifestations and complications of COVID-19 infection mimicking heart disease should also have been ruled out
In COVID-19-infected patients with clinical presentation compatible with CVD, three main entities should be considered:
- Patients with COVID-19 infection can present cardiac events, that can be favoured by the infection or unrelated. Those include ACS (STEMI and NSTEMI), acute HF, arrythmias, thoromboembolic events, CS, and cardiac arrests. Those syndroms require a quick diagnosis and management, and should not be overlooked due to the presence of COVID-19 infection;
- Infection-related cardiac injury can also lead to a clinical presentation suggestive of cardiac event, and should also be considered as a differential diagnosis.
- Patients with COVID-19 infection can present with symptoms mimicking CV events, including chest pain, dyspnoea, and shock, even in the absence of cardiac injury.
8. Categorization of Emergency/Urgency of Invasive Procedures
The rearrangement of the healthcare service required to face the COVID-19 pandemic has posed a series of relevant issues on prioritization of cardiac invasive procedures.136 Different regions in Europe and worldwide differ substantially in terms of local healthcare resources, epidemic density of the COVID-19 outbreak, changes of the epidemic over time and therefore access to healthcare services other than COVID-19 care. These differences have a wide range of implications for national/regional healthcare services, national health care authorities and in-hospital redistribution of resources. Regions (also within the same country) may be categorized into three groups according to the degree of involvement in the epidemic, with subsequent different implications for the healthcare system as summarized in Table 7.
The indications provided in this document refer mainly to the scenario of heavy involvement and, in part, to the scenario of moderate involvement. Importantly, healthcare services should continue to be provided according to standard-of-care as described by current clinical practice guidelines, as long as the degree of regional involvement in the epidemic allows it. The rationale to importantly reduce the number of elective hospitalizations is three-fold:
- To increase capacity for COVID-19 patients;
- To reduce the unjustified exposure of individuals (i.e. patients in need of non-urgent procedures and their relatives) to the hospital and surrounding environment;
- To reduce the exposure of health care providers to asymptomatic COVID-19 patients.
This strategy comes at the expense of time-to-treatment delays for urgent CV interventions and extension of waiting times for patients in need of elective coronary, heart valve or other CV interventions.
In this context, a strategy is needed to identify patients who are in a condition allowing to postpone procedures and those who are not. An obvious concern is to maintain the standard-of-care and timely access of patients with ACS including AMI to reperfusion therapy. In patients with chronic coronary syndromes (CCS), principles of prioritization can be based on risk stratification, taking into account prognostic implications of symptoms and the presence of known critical disease of the left main stem or of the proximal left anterior descending (LAD) coronary artery at prior coronary angiogram or at CCTA.137 Similarly, patients with decompensated, symptomatic, severe aortic stenosis (AS) scheduled for transcatheter aortic valve replacement should be prioritized.138 Table 8 summarizes a categorization of invasive cardiac procedures according to urgency that may be implemented at areas affected by the COVID-19 outbreak.
9. Management/Treatment Pathways
9.1. Non-ST-Segment Elevation Acute Coronary Syndromes
The management of patients with NSTE-ACS should be guided by risk stratification.113 Testing for SARS-CoV‑2 should be performed as soon as possible following first medical contact, irrespective of treatment strategy, in order to allow HCP to implement adequate protective measures and management pathways (section 5). Patients should be categorized into 4 risk groups (i.e. very high risk, high risk, intermediate risk, and low risk) and managed accordingly (Figure 12).
Patients with Troponin rise and no acute clinical signs of instability (ECG changes, recurrence of pain) might be managed with a primarily conservative approach. Non-invasive imaging using CCTA may speed-up risk stratification, avoid an invasive approach139 allowing early discharge.
For patients at high risk, medical strategy aims at stabilization whilst planning an early (< 24 hours) invasive strategy. The time of the invasive strategy may however be longer than 24 hours according to the timing of testing results. If feasible, a dedicated area to manage these patients while waiting for the test result should be arranged in the emergency department. In the case of positive SARS-CoV‑2 test, patients should be transferred for invasive management to a COVID-19 hospital equipped to manage COVID-19-positive patients.
Patients at intermediate risk should be carefully evaluated taking into consideration alternative diagnoses to T1MI, such as Type II MI, myocarditis, or myocardial injury due to respiratory distress or multiorgan failure or Takotsubo. In the event any of the differential diagnoses seem plausible, a non invasive strategy should be considered and CCTA should be favored, if equipment and expertise are available.
When there is a positive SARS-CoV‑2 test, patients should be transferred for invasive management to a COVID-19 hospital equipped to manage COVID-19-positive patients. At times of high demand on the infrastructure and reduced availability of catheterization laboratories or operators, non-invasive conservative management might be considered with early discharge from the hospital and planned clinical follow-up.
9.2. ST-Segment Elevation Myocardial Infarction
The COVID-19 pandemic should not compromise timely reperfusion of STEMI patients. In line with current guidelines, reperfusion therapy remains indicated in patients with symptoms of ischaemia of < 12 hours duration and persistent ST-segment elevation in at least two contiguous ECG leads.114 Concurrently, the safety of HCP should be ensured.136 To that purpose, and in the absence of previous SARS-Co-V2 testing, all STEMI patients should be managed as if they are COVID-19 positive. We provide general guidance to address the healthcare system organization and delineate possible pathways for specific STEMI settings. The proposed actions are not evidence-based, may need to be adapted to meet local hospital and health authority regulations and may be subject to change in view of the evolving COVID-19 pandemic. While general measures for healthcare systems on redistribution of hub and spoke hospital networks for CV emergency and reorganization of ED and hospital paths are described in sections 7 and 8, respectively, the main principles of STEMI management in the COVID-19 pandemic are the following:
- The maximum delay from STEMI diagnosis to reperfusion of 120 minutes should remain the goal for reperfusion therapy under the following considerations:
- Primary PCI remains the reperfusion therapy of choice if feasible within this time frame and performed in facilities approved for the treatment of COVID-19 patients in a safe manner for healthcare providers and other patients;
- Primary PCI pathways may be delayed during the pandemic (up to 60 minutes – according to multiples experiences) due to delays in the delivery of care and the implementation of protective measures;
- If the target time cannot be met and fibrinolysis is not contraindicated, fibrinolysis should then become first line therapy;
- As SARS-CoV‑2 test results are not immediately available in STEMI patients, any STEMI patient should be considered potentially infected;
- All STEMI patients should undergo testing for SARS-CoV-2 as soon as possible following first medical contact irrespective of reperfusion strategy, at the latest upon admission to the ICU post primary PCI. Until the result of the test is known, all precautionary measures should be taken to avoid potential infection of other patients and HCP;
- Consider immediate complete revascularization if indicated and appropriate in order to avoid staged procedures and reduce hospital stay;
- All physicians involved in the management of patients with STEMI should be familiar with indications, contraindications and dosage of fibrinolysis and adhere to established administration protocols (Table 9 and Table 10).
Specific pathways for management of STEMI patients are illustrated in Figure 13. It is suggested to perform left ventriculography during catheterization of any ACS patients to reduce the need for echocardiography and shorten hospital stay.
The treatment of the non-culprit lesions should be managed according to patients’ clinical stability as well as angiographic features of those lesions. In the presence of persistent symptomatic evidence of ischaemia, subocclusive stenoses, and/or angiographically unstable non-culprit lesions, PCI during the same hospitalization should be considered. Treatment of other lesions should be delayed, planning a new hospitalization after the peak of the outbreak.
9.3. Cardiogenic Shock
- Management of CS and OHCA is critically time-dependent requiring a dedicated network and multidisciplinary expertise;
- Resource allocation should still try to deliver a standardized team-based approach including availability and feasibility of mechanical circulatory support (MCS);
- Invasive coronary angiography (ICA) remains the mainstay of treatment. However, special considerations need to be taken into account to minimize the risk of widespread nosocomial infections;
- In patients with concomitant COVID-19 infection, escalation to MCS should be carefully weighed against the development of coagulopathy associated with COVID-19 infection and the need for specific treatment (prone position) required for acute lung injury;
- In case of requirement for MCS, extracorporeal membrane oxygenation (ECMO) should be the preferred temporary MCS because of the oxygenation capabilities;
- In case of acute renal failure, continuous renal replacement should be used restrictively according to established criteria;
- Daily SOFA and therapeutic intervention scoring system (TISS) scores should be assessed, for most critical patients, in order to improve decision making;
- The safety of HCP is of predominant importance to avoid any HCP infections.
CS and OHCA are time-dependent diseases needing relevant resources and optimal trained systems and dedicated networks for optimal outcome. In general, treatment of CS and OHCA should follow current guidelines and current evidence.101,114,137,140,141 However, considering that in an overwhelmed critical care system stressed by the pandemic COVID-19 infection it will not be possible for all the patients to receive ICU treatment due to limited resources. This leads to difficult situations based also on the four widely recognized principles of medical ethics (beneficence, non-maleficence, respect for autonomy and equity) which are also crucial under conditions of resource scarcity. If resources available are insufficient to enable all patients to receive the ideally required treatment, then multiple groups have considered and recommend fundamental principles to be applied in accordance with the following rules of precedence:
- Equity: Available resources are to be allocated without discrimination (i.e. without unjustified unequal treatment on grounds of age, sex, residence, nationality, religious affiliation, social or insurance status, or chronic disability). The allocation procedure must be fair, objectively justified and transparent. With a fair allocation procedure, arbitrary decisions, in particular, can be avoided;
- Preserving as many lives as possible: Under conditions of acute scarcity, all measures are guided by the aim of minimising the number of deaths. Decisions should be made in such a way as to ensure that as few people as possible become severely ill or die;
- Protection of the professionals involved: Therefore, triage protocols are needed in order to maximize benefits and relieve HCP from improvising decisions about whom to treat or making them in isolation.
Triage strategies, based on current evidence and a previously established critical care triage protocol developed by working groups for use during a worldwide influenza pandemic,142 are summarised in Table 11 and Table 12. Specific recommendations are provided for patients with and without concomitant infection in Figure 14. Two scenarios will be considered:
- Non-infected patients
- Possibly infected/COVID-19 positive patients.
The infection should be suspected according to recently defined epidemiological and clinical criteria.143
9.4. Chronic Coronary Syndromes
HCP managing patients with CCS in geographical areas heavily affected by the COVID-19 pandemic should consider the following main points:
- CCS patients are generally at low risk of CV events allowing to defer diagnostic and/or interventional procedures in most of the cases;
- Medical therapy should be optimized and/or intensified depending on the clinical status;
- Remote clinical follow-up should be warranted to reassure patients and capture possible changes in clinical status that might require hospital admission in selected high-risk profile patients.
9.4.1. Practical Considerations on Medical Therapy
Nonsteroidal anti-inflammatory drugs (NSAIDs) have been identified as a potential risk factor for serious clinical presentation of SARS-CoV‑2 infection.144 Potential impact of chronic aspirin therapy has been questioned. However, at the low dose administered in CCS, aspirin has very limited anti inflammatory effect. Therefore, CCS patients should not withdraw aspirin for secondary prevention.
Statin therapy has been variably associated with favourable outcomes in patients admitted with influenza or pneumonia.145,146 On the other side, patients with COVID-19 have been sometimes reported to develop severe rhabdomyolysis or increased liver enzymes.147 In these latter cases, it may be prudent to temporarily withhold statin therapy.
For CCS patients treated with antihypertensive drugs please refer to section 9.7.
9.4.2. Non-Invasive Testing
Non-invasive testing in patients with CCS is tailored upon different clinical presentations.148 In regions with high rate of SARS-CoV‑2 infection, evaluation of asymptomatic CCS patients with non invasive testing should be postponed in order not to expose these patients to an unnecessary risk of infection or overload the health care systems.
For symptomatic patients with suspected CAD and a pre-test probability of 5–15%, functional imaging for detection of myocardial ischaemia or CCTA are normally recommended as initial tests to diagnose CAD. In regions with critical situation and medical system overloaded by the COVID-19 pandemic, CAD screening even in symptomatic patients should probably be postponed in the majority of patients. Yet, if necessary, depending upon local availability and expertise, CTA should be preferred (section 7.4).
However, the increased workload of CT departments should be acknowledged; they have been heavily disrupted by the high request of pulmonary CT for patients with COVID-19. In addition, feasibility/accuracy of CCTA might be hampered in patients with COVID-19 for the common occurrence of tachycardia and at times severe renal dysfunction. In case CCTA is not suitable (e.g. inability of heart rate control, etc.) or available, non-invasive testing should be postponed. Alternative imaging modalities should be discouraged during the acute pandemic phase unless severe ischaemia is suspected, to minimize the access of the patients to healthcare system (SPECT/PET) or to prevent a close contact between patients and personnel (stress echocardiography).
For known CCS patients, clinical follow-up should be done mostly via tele-health (a dedicated telephone line should be made available to patients). Physicians could therefore address most of the patients’ concerns related to continuation or changes in medical therapy. Possible onset/recurrence of unstable symptoms should be estimated within the clinical history of the patient in order to weigh the need for hospitalization and diagnostic testing.
9.4.3. Invasive Assessment and Revascularization
Symptomatic patients with very high clinical likelihood of obstructive CAD are generally referred to ICA without prior non-invasive diagnostic testing.148 However, even in these patients, medical treatment should be attempted first in order to reserve ICA with possible ad-hoc revascularization only in case of clinical instability, especially in regions were healthcare systems are heavily overloaded by patients with COVID-19.149 Revascularization (either by PCI or coronary artery bypass graft [CABG]), can be postponed in most CCS patients. However, in hospitals whose ICUs are dedicated to or overloaded with high numbers of patients with COVID-19, the impact on CABG deferral might be even more pronounced. Priority is given to keep ICU beds available for COVID-19 patients requiring critical care. Therefore, healthcare systems might identify COVID-19-free hospitals serving as hubs for selected CCS patients in whom invasive and surgical procedures cannot be postponed. In these latter patients, SARS-CoV‑2 infection should be ruled out by nasopharyngeal swab/tracheobronchial aspiration and/or CT scan before hospital admission. Alternatively, in selected patients, hybrid revascularization CABG/PCI or even full-PCI can be considered by the heart team based on patient’s clinical conditions and local situation (see Table 13).
9.5. Heart Failure
Patients with CV comorbidities are at increased risk of the more severe presentation and complications of COVID-19. In a meta-analysis of 6 studies (n = 1527), hypertension and cardio/cerebrovascular diseases were present in 17.1%, and 16.4%, of hospitalized COVID-19 patients, respectively, and conferred ~2-fold and ~3-fold higher risk, respectively, for the more severe COVID-19.150
9.5.1. Acute Heart Failure
- Acute HF may complicate the clinical course of COVID-19, particularly in severe cases;
- Underlying mechanisms of acute HF in COVID-19 may include acute myocardial ischaemia, infarction or inflammation (myocarditis), ARDS, acute kidney injury and hypervolaemia, stress-induced cardiomyopathy, myocarditis and tachyarrhythmia;
- COVID-19 pneumonia may lead to the worsening haemodynamic status due to hypoxaemia, dehydration and hypoperfusion;
- Clinical presentation, pre-existing CV comorbidities, and chest imaging findings suggestive of HF (e.g. cardiomegaly and/or bilateral pleural effusion) are of an utmost importance;
- Significantly elevated BNP/NT-proBNP levels also suggest acute HF. Prudent use of bedside point of care (POC) transthoracic echocardiography (TTE) could be considered, with an attention to prevent contamination from the patient of the personnel and/or the equipment;
- The same treatment strategy for acute HF can be applied in patients with and without COVID-19. Data on acute HF in COVID-19 are scarce. In one report, 23% of all hospitalized patients developed HF, whilst HF prevalence was significantly higher in fatal cases compared with survivors (52% vs. 12%, P < 0.0001).34
In 21 patients admitted to an ICU for severe COVID-19, 7 (33.3%) patients developed dilated cardiomyopathy, characterized by globally decreased LV systolic function, clinical signs of CS, elevated creatine kinase (CK), or troponin I levels, or hypoxaemia, without a past history of systolic dysfunction.89 An analysis of mortality causes in COVID-19 patients (150 hospitalized/68 dead) revealed that myocardial damage/HF and combined respiratory failure/myocardial damage/HF were responsible for 7% and 33% of fatal cases, respectively.66
There are several, not mutually exclusive, mechanisms of acute HF in COVID-19 such as:
- Acute myocardial injury (defined as serum hs-cTn I elevation > 99th percentile of the ULN or new abnormalities in ECG or echocardiography) occurs in 8% of COVID-19 patients.150 It may be caused by ischaemia, infarction or inflammation (myocarditis). In patients with severe infection, evidence of acute myocardial injury is present in 22.2–31%.10,34,65 A meta analysis of four studies (n = 341) suggested that in patients with severe infection, hs-cTn I was significantly higher at admission (mean standardized difference 25.6 ng/L) compared to those with non severe course.151 In addition, troponin levels remained high in non-survivors throughout the clinical course and increased with illness deterioration.34 A history of HF was more frequently noted in patients with, compared to those without, acute myocardial injury (14.6% vs. 1.5%).26 Acute myocardial injury was also more frequently associated with significantly elevated NT-proBNP levels (median 1689 pg/mL);26
- ARDS, hypoxaemia, acute kidney injury, hypervolaemia, stress-induced cardiomyopathy and a profound systemic inflammatory activation (‘cytokine storm’), characteristic of severe infection and multiorgan dysfunction, could also contribute to acute HF or exacerbation of chronic HF in COVID-19;
- Sustained/repetitive cardiac arrhythmia may also lead to deterioration in cardiac function. Cardiac arrhythmia has been described in 16.7% of all hospitalized COVID-19 patients and in 44.4% of patients requiring intensive care admission.10
- Limited clinical experience indicates that SARS-CoV‑2 may lead to fulminant myocarditis;
- Myocarditis should be suspected in patients with COVID-19 and acute-onset chest pain, ST segment changes, cardiac arrhythmia and haemodynamic instability. In addition, LV dilatation, global/multi-segmental LV hypocontractility (on POC echocardiography), and significant increase in cardiac troponin and BNP/NT-proBNP levels, without significant CAD could also be present;
- Suspicion of myocarditis should be raised in COVID-19 patients with acute HF/CS without pre existing CV disorder;
- CCTA should be the preferred approach to rule out concomitant CAD;
- CMR (if available) may be used for further diagnostic assessment;
- Endomyocardial biopsy is not recommended in COVID-19 patients with suspected myocarditis;
- No clear recommendation can be given for SARS-CoV‑2-associated myocarditis treatment.
Incidence, underlying mechanisms and risk factors of SARS-CoV‑2-associated myocarditis are currently unclear. Recently, a high viral load has been reported in 4 patients who subsequently developed fulminant myocarditis.33 One published case involved a 38-year-old male presenting with chest pain, hypotension, bilateral pneumonia with pleural effusions and ST segment elevation, but with normal CT coronary angiogram.104 Echocardiography demonstrated dilatation and a marked decrease in LV ejection fraction (LVEF), and a 2 mm thick pericardial effusion. Troponin I and BNP levels were notably high. The patient successfully recovered after receiving high-dose parenteral glucocorticoid anti inflammatory therapy and immunoglobulin, along with other therapeutic measures.
9.5.3. Chronic Heart Failure
- The risk of COVID-19 infection may be higher in chronic HF patients due to the advanced age and presence of several comorbidities;
- In HF patients suspected of COVID-19, routine clinical assessment, temperature measurement with noncontact devices, ECG (arrhythmias, myocardial ischaemia, myocarditis), chest X-ray (cardiomegaly, COVID-19 pneumonia) and laboratory findings (elevated sedimentation rate, fibrinogen and C-reactive protein, and lymphocytopenia) can provide a diagnostic clue;
- TTE and chest CT scan can be used for further assessment. Attention should be given to the prevention of viral transmission to healthcare providers and contamination of the equipment;
- Patients with chronic HF should closely follow protective measures to prevent infection;
- Ambulatory stable HF patients (with no cardiac emergencies) should refrain from hospital visits;
- Guideline-directed medical therapy (including beta-blocker, ACEI, ARB or sacubitril/valsartan and mineralocorticoid receptor antagonist), should be continued in chronic HF patients, irrespective of COVID-19;
- Telemedicine should be considered whenever possible to provide medical advice and follow up of stable HF patients.
22.214.171.124. Prevention of SARS-CoV‑2 Infection
During the COVID-19 outbreak, patients with chronic HF should be advised to closely follow protective measures aimed at preventing disease transmission (e.g. self-isolation, social distancing, frequent hand washing, use of hand sanitizers and wearing a face mask in public spaces). Ambulatory stable HF patients (with no cardiac emergencies) should refrain from hospital visits.
126.96.36.199. Diagnostic Hints
Routine clinical methods, ECG (arrhythmias, myocardial ischaemia, myocarditis) and chest X-ray (cardiomegaly, COVID-19 pneumonia) can provide a diagnostic clue. Due to the relatively low sensitivity of chest X-ray to detect COVID-19 pneumonia, patients with a high degree of clinical suspicion (tachypnoea, hypoxaemia), but with ambiguous chest X-ray findings, should be referred to chest CT.152 Laboratory findings, such as increased erythrocyte sedimentation rate, fibrinogen and C-reactive protein, and lymphocytopenia, may suggest COVID-19 pneumonia. TTE is very important, not only to evaluate pre-existing LV dysfunction in HF, but also to assess patients suspected of having SARS CoV 2-associated myocarditis.153 During all medical procedures, an attention should be given to prevent viral transmission to HCP.
188.8.131.52. Chronic Heart Failure Treatment
SARS-CoV‑2 utilizes the ACE2 receptors for cell entry and some data indicate that ACEIs and ARBs may upregulate ACE2,154 thus hypothetically increasing the susceptibility to the infection. Recently, a case series of 12 patients with COVID-19-associated ARDS, demonstrated that plasma Ang II levels were markedly elevated and linearly associated with viral load and lung injury.33 This has led to a suggestion that ARB treatment could have a beneficial effect in curbing the Ang II-mediated lung injury. Clearly, further research in required to resolve the controversies regarding the role of ACEI/ARB in COVID-19.
There is currently no clinical evidence of an association between ACEI/ARB treatment and the susceptibility to infection, or the clinical course. Withdrawal of medical treatment in HF patients may increase the risk of worsening HF.155 Available data do not support discontinuation of ACEI/ARB and it could be recommended that HF patients continue guideline-directed medical therapy, including beta blockers, ACEI, ARB, or sacubitril/valsartan, and mineralocorticoid receptor antagonists, irrespective of COVID-19.156
COVID-19 patients may become hypotensive due to dehydration and haemodynamic deterioration, hence adjustment of medication doses should be considered.
184.108.40.206. Telemedicine and Home Drug Delivery
The more widespread use of telemedicine should be encouraged to minimize the risk of SARS-CoV‑2 transmission, in both HF patients, and HCP. Whenever possible, this technology should be utilized to provide medical advice and follow-up of stable HF patients, and to reserve direct patient provider contact for the emergency situations. It is advisable that HCP make a telephone contact with the ambulatory chronic HF patient to verify the need for the hospital visit, but also to provide psychological support. If feasible (and necessary), home delivery and mailing of standard HF drugs to the patients is a viable option.
9.5.4. Left Ventricular Assist Device and Heart Transplantation
- LVAD patients have greater susceptibility to the infection, and strict preventive measure should be applied to avoid it;
- Heart transplant recipients may be at a higher risk of severe COVID-19 disease or prolong viral shedding, hence tight adherence to preventive measures should be advised to avoid infection;
- Limited data exists about the presentation and prognosis of COVID-19 in heart-transplant recipients. However, variable clinical outcomes in solid organ recipients in earlier coronavirus outbreaks (SARS and MERS),157,158 suggest that hospitalization, close monitoring and appropriate treatment of COVID-19 heart-transplant patients should be recommended.
Due to the nature of the device, LVAD patients have an increase susceptibility to the infection, and every measure should be used to prevent viral transmission. Cautious monitoring and management of anticoagulation therapy is advised, because both COVID-19 and antiviral medications can affect anticoagulant dosing. If technically feasible, assessment of LVAD function by telemonitoring is preferable. General recommendations for all LVAD patients should be also applied, regardless of COVID-19.
The susceptibility to the infection and the clinical course of COVID-19 in heart transplant recipients is not known. Recently, two cases (one mild, another more severe) of COVID-19 have been described in heart transplant recipients in China.159 Importantly, the presenting symptoms were similar to those of immunocompetent individuals, including fever, elevated inflammatory markers (e.g. C-reactive protein), lymphocytopenia and chest CT demonstrating bilateral ground-glass opacities. The treatment of the patient with more severe infection included temporary discontinuation of baseline immunosuppressant medications and institution of high-dose glucocorticoids, immunoglobulins and fluroquinolone antibiotics, along with other treatment measures. Of note, both patients recovered and remained rejection-free.
Yet another report of 87 heart transplant recipients from China, indicated that high-degree adherence to preventive measures (see above), resulted in a low rate of possible infection and transition to manifest illness (e.g. 4 patients were reported to have airway tract infection and 3 of them had a negative SARS-CoV‑2 test result, whilst 1 patient was not tested).160 Importantly, all patients fully recovered after treatment.
9.6. Valvular Heart Disease
- Patients with valvular heart disease (VHD) (particularly those with associated left or right ventricular impairment, or pulmonary hypertension) may be at particular risk during the COVID-19 pandemic;
- Coordinated allocation of resources at hospital and regional level is essential to sustain ICU capacity;
- Maintained function of the Heart Team is paramount (even if face-to-face meetings are not feasible).
Although VHD has not been explicitly linked to increased morbidity and mortality in early COVID-19 case series, up to 40% of the patients admitted to the ICU had pre-existing congestive HF.89 VHD mainly affects the elderly and the symptoms of disease progression (mainly dyspnoea) may mimic those of lung infection or infiltration. In addition, VHD may aggravate the course of COVID-19 infection and complicate haemodynamic management of the systemic inflammatory response (cytokine storm),161 ARDS, and any superimposed bacterial septicaemia (observed in up to one third of ICU patients).65
Elective surgical and transcatheter interventions for VHD consume significant health care resources and many (or all, according to circumstances) may be inappropriate during the pandemic given the immense pressure on acute and intensive care facilities. However, patients with severe VHD must remain under close telephone surveillance and be encouraged to report progressive symptoms. Concentration of resources on the treatment of pandemic victims guides decisions with the overall aim of avoiding shortage of ICU beds and ventilators. Prioritization of valve interventions should therefore balance the immediate and short-term prognosis of individual patients against available resources and the risk to patients and HCP of acquiring in-hospital infection. In this respect, use of less invasive procedures (particularly transcatheter aortic valve implantation [TAVI] via transfemoral approach performed under conscious sedation and/or local anaesthesia), may present an opportunity to minimize ICU and hospital stay. The need for clinical decision making by Heart Teams remains of paramount importance and use of telemedicine (or other means of virtual communication) is essential if face-to-face meetings are difficult (or impossible) during the acute phase of the pandemic.
9.6.1. Management of Aortic Stenosis
- Priority should be given to patients with syncope and HF, and those with high (or very high) gradients and/or impaired LV function;
- Non-urgent procedures should be deferred based on objective criteria assessed by the Heart Team;
- Greater use of transfemoral TAVI (as judged appropriate by the Heart Team) may allow optimal utilization of healthcare resources.
The prognosis of patients with severe aortic stenosis (AS) depends on several factors, including age, symptomatic status, peak aortic jet velocity/mean transvalvular gradient,162,163 LVEF, pulmonary hypertension,164 and elevated biomarkers (natriuretic peptides or troponin).165-167 Mortality of patients with severe symptomatic AS who are treated conservatively is high, reaching 50% at 1 year and 70–80% at 2 years.168 Deferring surgical aortic valve replacement (SAVR) or TAVI by several months may therefore affect prognosis.
In the context of the COVID-19 pandemic, the Heart Team should undertake systematic individual risk assessment based on objective criteria that determine disease progression. Priority should be given to patients with syncope or HF (New York Heart Association [NYHA] Class III/IV), high or very high transvalvular gradients and those with reduced LV function Table 8, whereas a watchful waiting strategy is more appropriate in those with minimal or no symptoms. TAVI (or balloon aortic valvuloplasty) may be considered in haemodynamically unstable patients (COVID-19 positive/negative). However, the potential benefits of valve intervention in a critically ill COVID-19 positive patient (no cases reported to date) should be carefully weighed against the likelihood of futility given the > 60% mortality of COVID-19 positive patients admitted to ICU.169
All cases should be discussed by the Heart Team and indications for TAVI extended to intermediate170,171 and selected low-risk patients.172,173 Increased use of transfemoral TAVI (when feasible) may allow optimal utilization of resources by avoiding general anaesthesia and intubation, shortening (or preventing) ICU stay and accelerating hospital discharge and recovery.174
9.6.2. Management of Mitral Regurgitation
- The majority of patients with mitral regurgitation (MR) are stable and surgical or transcatheter intervention can be deferred;
- Priority should be given to the treatment of patients with acute MR complicating AMI or infective endocarditis (IE), and those with severe symptomatic primary MR or secondary MR (SMR) that is not responsive to guideline-directed medical and device treatment and seems likely to require hospital admission. The choice of intervention should be guided by the Heart Team.
The management of MR differs according to its aetiology and presentation. Chronic primary MR (flail leaflet and Barlow disease) is usually stable and well tolerated. In contrast, SMR is a more variable entity and whilst many patients remain stable under guideline directed medical and device treatment (including sacubitril/valsartan and cardiac resynchronization therapy when indicated),175 others may develop unstable HF syndromes that are refractory to medical treatment, particularly in the context of acute infection.176
In the context of the COVID-19 pandemic, priority should be given to the treatment of patients with acute primary MR complicating AMI or IE, and those with severe primary or SMR who remain symptomatic despite guideline-directed medical and device treatment and seem likely to require hospital admission. All other patients should be managed conservatively.175-178
Transcatheter mitral edge-to-edge repair may be considered in anatomically suitable high-risk or inoperable patients with acute MR (excluding those with IE) or highly selected patients with decompensated primary MR or SMR refractory to guideline-directed medical and device treatment. Despite a low risk of complications requiring ICU admission,179 the procedure requires general anaesthesia (in distinction to transfemoral TAVI) and prolonged echocardiographic guidance, thereby exposing interventionists and anaesthetists to the risk of COVID-19 transmission. Use of temporary circulatory support (intra-aortic balloon pump or Impella) should be restricted to patients with a good prospect for recovery in the context of available ICU resources.
- It now seems likely that the reported association between hypertension and risk of severe complications or death from COVID-19 infection is confounded by the lack of adjustment for age and comorbidities associated with ageing and hypertension. There is currently no evidence to suggest that hypertension per se is an independent risk factor for severe complications or death from COVID-19 infection;
- Despite much speculation, evidence from a recently published series of observational cohort studies suggests that prior or current treatment with ACEIs or ARBs does not increase the risk of COVID-19 infection when compared to the risk in patients taking other antihypertensive drugs;
- Treatment of hypertension should follow existing recommendations in the ESC-European Society of Hypertension (ESH) Guidelines. No change to these treatment recommendations is necessary during the COVID-19 pandemic;
- Self-isolated patients with treated hypertension should not need to attend hospital for routine review visits during this pandemic. Patients could make use of periodic home BP monitoring, with videoconference or phone consultations only if needed;
- Hypertensive patients may be at increased risk of cardiac arrhythmias due to underlying cardiac disease, or the reported high frequency of hypokalaemia in patients with severe COVID-19 infection;
- Antihypertensive therapy may need to be temporarily withdrawn in acutely ill patients in hospital who develop hypotension or acute kidney injury secondary to severe COVID-19 infection;
- In patients previously treated for hypertension who require invasive ventilation, parenteral antihypertensive medication is only indicated for those developing persistent severe hypertension.
9.7.1. Hypertension and COVID-19
Initial reports from China noted that hypertension was one of the most common co-morbidities (20–30% of cases) associated with the need for ventilatory support due to severe respiratory complications of COVID-19 infection.10,65,80,99,180 These analyses did not adjust for age, which is important because hypertension is very common in older people (~50% in people aged over 60 years are hypertensive) and hypertension prevalence increases sharply in the very old. Older age is also the most important risk factor for severe complications and death due to COVID-19, thus, a high frequency of hypertension would be expected in older patients with severe infection because of their older age. Indeed, a higher frequency of hypertension would be expected in older COVID-19-infected patients, than has been reported.
It now seems likely that the reported association between hypertension and risk of severe complications or death from COVID-19 infection is confounded by the lack of adjustment for age and other unmeasured confounders.47 There is currently no evidence to suggest that hypertension per se is an independent risk factor for severe complications or death from COVID-19 infection.
9.7.2. Antihypertensive Treatment with Angiotensin Converting Enzyme Inhibitors or Angiotensin Receptor Blockers
RAS blockade with ACEIs or ARBs are the foundation of antihypertensive therapy in the current ESC-ESH Guidelines for the management of arterial hypertension (2018).181 The recommended treatment of hypertension for most patients is combinations of an ACEI or ARB with a calcium channel blocker (CCB) or thiazide/thiazide like diuretic.181
Concern has been expressed that treatment with ACEIs or ARBs might increase the risk of infection, or developing the severe consequences of infection with COVID-19.21,46,182 This concern originates from a hypothesis that links the observations that COVID-19 invades cells by binding to the enzyme ACE2 which is ubiquitous and expressed on the surface of alveolar cells in the lung.39,41,183 In some animal studies, but not all, ACEIs or ARBs have been shown to increase ACE2 levels mainly in cardiac tissue.49,184,185
Importantly, there have been no studies showing that RAS-blocking drugs increase ACE2 levels in human tissues and no studies in animals or humans showing that RAS-blocking drugs increase ACE2 levels in the lung, or that the level of ACE2 expression in the lung is rate limiting for COVID-19 infection.
Moreover, there have been no studies in humans demonstrating an independent link between RAS blocker use and the development of severe complications of COVID-19 infection, after adjustment for age and other comorbidities. Recently a series of observational cohort studies have been published which consistently show that treatment with RAS blockers does not increase the risk of COVID-19 infection, or increase the risk of severe complications or death from COVID-19 infection.54-60 In one study, there was even a substantial reduction in risk of severe complications or death from COVID-19 infection in patients with diabetes mellitus.56 These recent findings are very important and provide reassurance to patients and their doctors that prior speculation about the safety of RAS blockers in the context of COVID-19 infection has not been proven.
Indeed, studies in animal models of infection with influenza or coronaviruses have suggested that ACE2 is important in protecting the lung against severe injury and that RAS-blocking drugs are also protective against severe lung injury due to these viruses.186-188 Human studies of RAS-blockade or recombinant ACE2 to prevent respiratory decompensation in COVID-19 infected patients have been suggested, planned or are ongoing.189,190
In summary, there is currently no evidence to suggest that ACEIs or ARBs increase the risk associated with COVID-19 infection and there is no reason why these drugs should be discontinued due to concern about COVID-19 infection. Treatment of hypertension when indicated, should continue to follow the existing ESC-ESH guideline recommendations.191
9.7.3. Remote Management of Hypertension in the Patient Isolated at Home
Most patients with hypertension require only infrequent visits to the clinic to manage their hypertension. Many patients with treated hypertension will be in self isolation to reduce the risk of COVID-19 infection and unable to attend for their usual routine clinical review. When possible, patients should monitor their own BP as frequently as they usually would, using a validated home BP monitor.181
Videoconference or telephone consultation with patients when required may facilitate urgent physician follow up until normal clinic attendance resumes.
9.7.4. Hypertension and the Hospitalized Patient with COVID-19 Infection
Most patients who are hospitalized, will have more severe infection and be hospitalized for respiratory support. They are likely to be older with comorbidities such as hypertension, diabetes and chronic kidney disease. Patients with severe disease may also develop multi-organ complications in severe disease.
Hypertensive patients may also have LV hypertrophy or heart disease and be at increased risk of developing arrhythmias, particularly when hypoxic.192 Plasma potassium levels should be monitored because arrhythmias may be exacerbated by the frequent occurrence of low plasma potassium levels or hypokalaemia that was first noted in SARS coronavirus infection193 and early reports suggests is also prominent in hospitalized COVID-19-infected patients.194 This is thought to be due to increased urinary loss of potassium, which may be exacerbated by diuretic therapy.
If patients are acutely unwell and become hypotensive or develop acute kidney injury due to their severe disease, antihypertensive therapy may need to be withdrawn. Conversely, parenteral antihypertensive drugs are rarely but sometimes needed for hypertensive patients who are ventilated and have sustained and significant increases in BP after withdrawal of their usual treatment (i.e. grade 2 hypertension, BP > 160/100 mmHg) but the objective in these acute situations is to maintain BP below these levels and not aim for optimal BP control.
9.8. Acute Pulmonary Embolism – Prevention and Diagnosis
- Consider anticoagulation at standard prophylactic doses in all patients admitted with COVID-19 infection;
- Consider the presence of acute PE in patients with COVID-19 infection in the setting of unexpected respiratory worsening, new/unexplained tachycardia, a fall in BP not attributable to tachyarrhythmia, hypovolaemia or sepsis, (new-onset) ECG changes suggestive of PE, and signs of deep vein thrombosis of the extremities;
- When acute PE is confirmed, treatment should be guided by risk stratification in accordance with the current ESC guidelines;
- Non-vitamin K antagonist oral anticoagulants (NOACs) may have interactions with some of the investigational drugs for COVID-19, notably lopinavir/ritonavir. In such cases, NOACs should be avoided. No major interactions have been reported between investigational drugs for COVID-19 and heparin anticoagulation.
Although solid evidence is unavailable to date, a number of case reports suggest that the incidence of PE in patients with COVID-19 infection may be high.195-197 Taking this into account, together with COVID-19-associated systemic inflammation, coagulation activation, hypoxaemia and immobilization, anticoagulation at standard prophylactic doses should be considered for all patients admitted to the hospital with COVID-19 infection.
Patients with COVID-19 infection often present with respiratory symptoms and may also report chest pain and haemoptysis.80 These symptoms largely overlap with the presentation of acute PE which may cause underdiagnosis of this relevant complication.198 Unexpected respiratory worsening, new/unexplained tachycardia, a fall in BP not attributable to tachyarrhythmia, hypovolaemia or sepsis, (new-onset) ECG changes suggestive of PE, and signs of deep vein thrombosis of the extremities should trigger a suspicion of PE. It is recommended to only order diagnostic tests for PE when it is clinically suspected, although it is recommended to keep a low threshold of suspicion. The specificity of D-dimer tests may be lower in patients with COVID-19 compared to other clinical settings. Even so, it is still advised to follow diagnostic algorithms starting with pre-test probability and D-dimer testing, especially when pre-test probability dependent D-dimer thresholds are being used.120-122 This may help to rationalize the deployment of resources and personnel for transporting a patient to the radiology department with all the associated isolation precautions. In the clinical scenario of a patient with COVID-19, who has just undergone CT of the lungs but the findings cannot explain the severity of respiratory failure, CT pulmonary angiography may [or should] be considered before leaving the radiology department.
When acute PE is confirmed, treatment should be guided by risk stratification in accordance with the current ESC guidelines.119 Patients in shock should receive immediate reperfusion therapy. Haemodynamically stable patients may be treated with either unfractionated heparin (UFH), low molecular weight heparin (LMWH) or a NOAC, depending on the possibility of oral treatment, renal function and other circumstances. When choosing the appropriate drug and regimen (parenteral versus oral) for initial, in-hospital anticoagulation, the possibility of rapid cardiorespiratory deterioration due to COVID-19 should be taken into account. Of note, some of the investigational drugs for COVID-19 may have relevant interactions with NOACs. In particular, this may be the case for lopinavir/ritonavir via Cytochrome P450 3A4 (CYP3A4) and/or P-glycoprotein (P-gp) inhibition. In such cases, the bleeding risk may be elevated and NOACs should be avoided. Because close monitoring is necessary which may contribute to spreading of the infection, vitamin K antagonists (VKAs) should only be considered in special circumstances such as the presence of mechanical prosthetic valves or the antiphospholipid syndrome.119
- For monitoring and follow up of patients with cardiac implantable devices, remote monitoring should be utilized as much as possible;
- Elective ablation and cardiac device implantation procedures should be postponed and urgent procedures should only be performed in exceptional cases after careful consideration of all pharmacological treatment options;
- In hospitalized patients with AF/atrial flutter without haemodynamic instability, discontinuation of AADs and initiation of rate control therapy to allow safe use of hydroxychloroquine and/or azithromycin as antiviral medication is a reasonable therapeutic option;
- Drug-drug interactions including antiviral, antiarrhythmic and anticoagulation drugs should be considered before administration;
- In critically ill patients with haemodynamic instability due to recurrent haemodynamically unstable VT/VF or AF/atrial flutter, i.v. amiodarone is the choice of antiarrhythmic medication. However, its combination with hydroxychloroquine and azithromycin should be preferably avoided;
- Special attention should be paid to the prevention of Torsades de Pointes (TdP) VT in the setting of COVID-19 and administration of QT interval (QT) prolonging antiviral drugs (hydroxychloroquine and azithromycin) in combination with AADs, electrolyte disturbances, kidney dysfunction, and/or bradycardia;
- Therapy of Torsades VT consists of withdrawal of all QT prolonging drugs, targeting K+ > 4.5 mEq/L), i.v. magnesium supplementation and increasing heart rate (by withdrawing bradycardic agents and if needed by i.v. isoproterenol or temporary pacing);
- Echocardiography should be considered in patients with new malignant ventricular arrhythmias not related to QT prolongation, to asses ventricular function and myocardial involvement;
- After recovery from the COVID-19 infection, in AF/atrial flutter the therapeutic choices of rate and rhythm control should be re-assessed, and long-term anticoagulation should be continued based on the CHA2DS2-VASc score. The need for permanent pacing in bradycardia and for catheter ablation, secondary prophylactic implantable cardiac defibrillator (ICD) or wearable defibrillator in ventricular tachyarrhythmia needs to be re-evaluated.
Very few data are available on antiarrhythmic management specifically in COVID-19 patients. Therefore, this text reflects a consensus based on limited evidence. This text will be updated if more information becomes available.
The general principles of management of patients with cardiac arrhythmias and cardiac implantable devices during the COVID-19 pandemic are based on:
- Preserving health care resources to allow appropriate treatment of all patients with COVID-19 infection;
- Minimizing the risk of nosocomial infection of non-infected patients and health care workers;
- Continuing to provide emergency high quality care safely to all patients with life-threatening cardiac arrhythmias and implantable devices.
Several national societies and health services including the Heart Rhythm Society, National Health Service (UK) and the Cardiac Society of Australia and New Zealand have issued similar local recommendations to achieve these goals and guide the management of patients with cardiac arrhythmias and cardiac implantable devices during the COVID-19 pandemic.199-201 Below, we review considerations for implantable cardiac device monitoring and follow-up, elective and urgent EP procedures and treatment options of cardiac arrhythmias during the COVID-19 pandemic.
9.9.1. Monitoring and Follow up of Patients with Cardiac Implantable Devices
9.9.2. Considerations for Electrophysiological and Implantable Device Procedures
The categorization of EP procedures in the context of COVID-19 is depicted in Table 14. In summary, all elective ablation and cardiac device implantation procedures should be postponed, and antiarrhythmic medications should be reviewed and intensified if necessary, to allow control of symptomatic arrhythmia recurrences during the COVID-19 pandemic period.
Urgent EP procedures in patients without suspected or confirmed COVID-19 infection should be performed in a designated non-infected catheterization laboratory area, while limiting direct contact with personnel, and with the appropriate use of PPE (Section 5) during the procedure. In patients with suspected or confirmed COVID-19 infection, the procedure should be performed in a designated catheterization laboratory area, while limiting direct contact with personnel, and with the appropriate use of PPE (Section 5) during the procedure. If intubation is required, this should be performed outside the EP laboratory to avoid contamination.
The hospital stay and all ancillary procedures (ECG, echocardiography) should be reduced to minimum and be performed after clinical reassessment of their necessity.
9.9.3. Management of Cardiac Arrhythmias in Patients with COVID-19 Infections
The incidence and type of cardiac arrhythmias as a direct consequence of COVID-19 infection is currently unknown. In a single centre retrospective study including 138 patients hospitalized with COVID-19 pulmonary infection in Wuhan, China, cardiac arrhythmias occurred in 23 patients (16.7%) and acute cardiac injury in 10 (7.2%) patients (defined as troponin rise, or new ECG and echocardiographic abnormalities). Cardiac arrhythmias were considered a major complication and occurred more frequently in patients who were transferred to the ICU as opposed to the patients treated on the general ward (16 [44%] of 36 patients vs. 7 [6.9%] of 102 patients, p < 0.001, respectively).10 However, the type and duration of arrhythmias was not specified in this report.
In general, the acute treatment of arrhythmias should not be significantly different from their management in non-COVID-19 patients and should be in line with the current ESC, European Heart Rhythm Association and related guidelines.202-208
220.127.116.11.1. Supraventricular Tachycardia
There are no specific reports on the incidence of non-AF/atrial flutter type of paroxysmal supraventricular tachycardia (PSVT) during COVID-19 infection. In theory, exacerbation of known PSVT or new-onset PSVT may occur in patients with COVID-19 infection. Special considerations during the COVID-19 pandemic are the transient unavailability of catheter ablation procedures for definitive treatment, the risk of nosocomial infection during repeated ED visits, and the possibility of therapy interactions with AADs (see Section 10).
- Intravenous adenosine can probably be used safely for acute termination, but confirmatory data are lacking;
- Maintenance therapy with beta-blockers (or CCBs if beta-blockers are contraindicated) should be initiated with low threshold. Drug interaction with antiviral drugs should be evaluated, including the avoidance of bradycardia to avoid excessive QT prolongation (see Section 10);
- After the COVID-19 pandemic, the indication for catheter ablation should be reassessed.
18.104.22.168.2. Atrial Fibrillation and Flutter
There are no specific reports on the occurrence of AF during COVID-19 infection. It is likely that AF may be triggered by COVID-19 infection (fever, hypoxia, adrenergic tone), either new onset or recurrent. In patients with severe pneumonia, ARDS and sepsis, the incidence of AF during hospitalization is known to be high. Reportedly 23–33% of critically ill patients with sepsis or ARDS had AF recurrence and 10% developed new-onset AF.202,209-211 New-onset AF in sepsis and ARDS has been associated with higher short- and long-term mortality, very high long-term recurrence rate and increased risk of HF and stroke.202,209-211 In a recent report from Italy, among 355 COVID-19 patients who died (mean age 79.5 years, 30% women), retrospective chart review identified a history of AF in 24.5%.18 This finding supports the estimates that especially older patients admitted to the hospital (and ICU) with COVID-19 associated pneumonia, ARDS and sepsis frequently develop new-onset or recurrent AF, which may further complicate management. Specific precipitating factors in this setting are hypokalaemia and hypomagnesaemia (induced by nausea, anorexia, diarrhoea and medications), metabolic acidosis, the use of inotropic agents (especially dobutamine and dopamine), ventilator dyssynchrony, volume overload, increased sympathetic tone, inflammation, hypoxia, ischaemia, bacterial superinfection and myocardial injury.202
As in all patients with AF, treatment goals have to consider ventricular rate control, rhythm control and thromboembolic prophylaxis. Specifically in the context of COVID-19 infection, the following considerations should be made (Figure 16):
- In patients with haemodynamic instability due to new-onset AF and atrial flutter, electrical cardioversion should be considered. This however needs to be balanced versus the need for more equipment and personnel at the side of the patients, and the possible need for intubation (with the risk of increased viral aerosol creation);
- In critically ill patients with haemodynamic instability due to new onset AF/atrial flutter, i.v. amiodarone is the choice of antiarrhythmic medication for rhythm control, however its combination with hydroxychloroquine and/or azithromycin should be preferably avoided. If it is used, the benefit of the treatment should be balanced against proarrhythmic risk due to QT prolongation (see section 10, Table 15);
- In patients with severe acute respiratory insufficiency, cardioversion is unlikely to provide sustained benefit without concomitant intensified treatment of the underlying hypoxaemia, inflammation and other reversible triggers such as hypokalaemia and hypomagnesaemia, metabolic acidosis, catecholamine infusion, volume overload, increased sympathetic tone and bacterial superinfection;
- In hospitalized patients under antiviral treatment with new-onset or recurrent AF/atrial flutter but without haemodynamic instability, discontinuation of AADs is preferred (especially sotalol and flecainide, but likely also amiodarone and propafenone) and initiation of rate control therapy with beta-blockers (or CCBs unless contraindicated, with or without digoxin; beware drug interactions) is preferred to allow safe antiviral medication use is a reasonable therapeutic option. Spontaneous cardioversion to sinus rhythm may occur within few hours to days in a proportion of stable COVID-19 patients with recent onset AF and mild to moderate clinical presentation without pronounced inflammation;
- In hospitalized patients with new-onset atrial flutter, rate control may be more challenging than AF. If the patient remains symptomatic or there are haemodynamic consequences, electrical cardioversion may be considered;
- Anticoagulation for the prevention of AF-related stroke or systemic embolism should be guided by the CHA2DS2-VASc score (and not AF clinical type or current rhythm status). Therapeutic anticoagulation should be considered in male and female patients with CHA2DS2-VASc score ≥ 1and ≥ 2, respectively, and is indicated in male and female patients with CHA2DS2-VASc score ≥ 2and ≥ 3, respectively;
- The need for an echocardiogram should be balanced against the need for close contact between HCP and patient, and contamination of equipment. Only when considered mandatory for immediate therapeutic management in the critically ill patient, it can be used to asses LV function and pericardial and myocardial involvement. TTE is in general preferred to TEE to avoid aerosol generation. If possible, TTE should be deferred until after convalescence;
- Similarly, TEE should be obviated by early start of anticoagulation in new-onset AF, or continuation in newly admitted COVID-19 patients with antecedent AF;
- Drug-drug interactions including antiviral, antiarrhythmic and anticoagulation drugs should be considered before administration.(see section 10, Table 15 and Table 16).
- After recovery from the COVID-19 infection, the therapeutic choices of rate and rhythm control should be re-assessed, and long-term anticoagulation should be continued based on the CHA2DS2-VASc score.
22.214.171.124.3. Ventricular Arrhythmias
Although there are no reports on the incidence of ventricular arrhythmias in the general population of patients with COVID-19 infection, a recent single centre retrospective study from Wuhan analyzed the occurrence and significance of malignant ventricular arrythmias in 187 hospitalized patients with confirmed COVID-19 infection. Among the 187 patients (mean age 58 ±14.7 years, 49% male), 43 (23%) patients died during hospitalization. Overall, 66 (35.3%) patients had underlying CVD including hypertension (32.6%), coronary heart disease (11.2%), and cardiomyopathy (4.3%), and 52 (27.8%) patients exhibited myocardial injury as indicated by elevated Troponin T levels. During hospitalization, malignant ventricular arrhythmias (defined as sustained VT or VF) occurred in 11 (5.9%) patients. VT/VF occurred more frequently in patients with elevated troponin levels (17.3% vs. 1.5%, p < 0.001).25 These findings suggest that new-onset malignant ventricular arrhythmia is a marker of acute myocardial injury and may warrant more aggressive immunosuppressive and antiviral treatment. In patients with a history of CVD and ventricular arrhythmias, exacerbation of the known VT/VF may occur due to COVID-19 infection as trigger. Although reports are not available for COVID-19, a correlation between increased appropriate ICD therapies and influenza epidemic has been shown.212
Special considerations during the COVID-19 pandemic are depicted in Figure 17 and summarized below:
- In unresponsive patients without breathing, the local Basic and Advanced Life Support protocol should be followed. During basic life support, ventilation is not performed, only cardiac compressions, to avoid the risk of ingestion of aerosols. For Advanced Life Support, only HCP with full PPE are eligible to perform intubation;
- In patients with VF, asynchronous defibrillation, and in patients with haemodynamically unstable VT, synchronized electrical cardioversion should be performed;
- In patients with sustained monomorphic VT:
- Electrical cardioversion should be considered in patients taking QT prolonging combination antiviral drugs, especially in case the patient is already ventilated;
- Intravenous procainamide (if available) or lidocaine, could be considered in patients taking QT prolonging combination antiviral drugs and if the haemodynamic status permits;
- Intravenous amiodarone could be considered in patients with known structural heart disease and impaired LV function; however, its action is slow for conversion of VT, and combination with hydroxychloroquine and azithromycin should be preferably avoided due to QTc effects. The benefit of treatment should be balanced against the increased proarrhythmic risk due to QT prolongation (see section 10, Table 15).
- In critically ill patients with COVID-19 infection and recurrent sustained VT and recurrent VF (‘VT storm’), i.v. amiodarone is the antiarrhythmic medication of choice. However, its combination with hydroxychloroquine and/or azithromycin should be preferably avoided and the benefit of treatment should be balanced against the increased proarrhythmic risk due to QT prolongation (see section 10, Table 15)
- Intravenous lidocaine may be considered as a safer but less effective alternative to amiodarone, especially if underlying myocardial ischaemia is suspected:
- Addition of sympathetic blockade (e.g. esmolol) should be considered;
- Intubation (with all the risk of viral spreading associated), sedation and ventilation may be considered to abort VT storm;
- Temporary PM implantation for overdrive termination may be considered, balancing the possible therapeutic benefit against the invasiveness of the lead placement with risk for personnel. In the absence of a functional cardiac catheterization laboratory, floatation guided temporary wire insertion may be considered in case of emergency;
- In patients with severe acute respiratory insufficiency, correction of underlying reversible triggers should be considered as hypoxia, hypovolaemia, electrolyte abnormalities as hypokalaemia and hypomagnesaemia, metabolic acidosis, catecholamine infusions, volume overload, increased sympathetic tone, tamponade, pneumothorax, ischaemia, bacterial superinfection and proarrhythmic drugs;
- Special attention should be paid to the prevention of TdP VT in the setting of COVID-19 infection;
- TdP is a polymorphic VT associated with QT prolongation and triggered by QT prolonging antiviral drugs (hydroxychloroquine and azithromycin), especially in combination with AADs (especially sotalol), electrolyte disturbances (in particular K+ and Mg2+), kidney dysfunction, and/or bradycardia, especially in females and in patients with LV hypertrophy or diminished LV function;
- Therapy of TdP VT consists of:
- Withdrawal of all QT prolonging drugs;
- Normalizing potassium level (target > 4.5 mEq/L);
- Intravenous magnesium supplementation;
- Increasing heart rate, by withdrawing bradycardic agents, and if needed by i.v. isoproterenol or temporary pacing (balancing benefit against the invasiveness of the lead placement with risk for personnel). Isoproterenol is contraindicated in the setting of congenital long QT syndrome (LQTS);
- Polymorphic VT without QT prolongation is not TdP but usually signals ischaemia or acute myocardial injury;
- Echocardiography should be considered in all patients with new malignant ventricular arrhythmias not related to QT prolongation, to assess ventricular function and myocardial involvement;
- After recovery from the COVID-19 infection the need for secondary prophylactic ICD, catheter ablation, or wearable defibrillator (in case of suspected transient cardiomyopathy due to myocarditis) needs to be evaluated.
There are no specific reports on the occurrence of COVID-19 infection in patients with channelopathies. However, COVID-19 infection may occur in patients with known congenital LQTS, Brugada syndrome (BS), catecholaminergic polymorphic ventricular tachycardia (CPVT) and short QT syndrome, with a risk of pro-arrhythmia. The specific interactions of these channelopathies and COVID-19 has been reviewed in a recent review.213
- Special considerations in congenital LQTS with COVID-19 infection is the combination of antiviral drugs (hydroxychloroquine and azithromycin) and stress factors (electrolyte disturbances and kidney dysfunction) that may further prolong QTc. The QTc should be monitored as closely as safe and practicable. All unnecessary QT prolonging drugs should be stopped, and if QTc > 500 ms or if QTc increases by ≥ 60 ms from baseline, then the safety of QT prolonging antiviral drugs should be reviewed and serum potassium levels should be kept at > 4.5 mEq/L. (Section 10, Figure 19);
- In BS with COVID-19 infection, the main concern is fever-triggered malignant ventricular arrhythmia. Therefore, in all COVID-19 patients with BS, fever should be aggressively treated with paracetamol. As shown in a recently published case-report, COVID-19-induced fever may lead to symptomatic BS.214 ECG monitoring should be considered if antipyretic therapy is ineffective and the temperature remains > 38.5ºC in higher risk BS patients (Figure 18, Panel A).
- In patients with CPVT and COVID-19 infection, beta-blockers and flecainide should be continued with monitoring of drug interactions with antiviral drugs (see section 10, Table 15) and in critically ill patients, catecholamine infusions should be administered with great caution, requiring permanent monitoring (Figure 18, Panel B).
In theory, exacerbation of known conduction system or sinus node disease or new-onset high degree AV block or sinus node dysfunction may occur in patients with COVID-19 infection, especially in case of myocardial involvement. Other mechanisms of AV block in COVID-19 are vagally mediated due to neuroinvasion, or hypoxia. A case of transient AV block in a critical COVID patient was recently published.215 One experimental study from 1999 has shown that coronavirus-infected rabbits have ECG abnormalities including 2nd degree AV block secondary to myocarditis and HF.212 In critically ill patients in the ICU, transient bradycardia and asystole may occur due to patient turning for prone respiration, intubation, or trachea suction and is probably due to transient increased vagal tone.202 Hypoxaemia should be ruled out.
A heart rate/temperature discordance was observed in patients with COVID-19:10,102 The heart rate at admission was about 80 beats per minute (bpm), slower than expected in these patients with fever. This has also been observed in other infectious disease such as typhoid fever.
Special considerations for permanent PM implantation in patients with COVID-19 are the poor prognosis of patients requiring mechanical ventilation, increased risk of bacterial superinfection and device infection in the critically ill patients, risk of nosocomial infection during device implantation in COVID-19 negative patients (see above) and transient bradyarrhythmic side effects of antiviral therapy.
- Some treatments used for COVID-19 might increase the likelihood for AV block or bundle branch block, such as chloroquine (less with hydroxychloroquine) or fingolimod (Table 15). Some of these effects might become apparent only after many weeks;
- Therefore, recovered COVID-19 patients should be alerted to symptoms of dizziness, presyncope or syncope, and be instructed to contact medical care if these occur;
- To avoid bradycardia as the result of drug-drug interactions, monitoring drug levels and dose adjustment may be required (see Section 10)
- In case of persistent symptomatic bradycardia due to AV block or recurrent sinus node dysfunction with pauses:
- All medication causing bradycardia should be stopped;
- Isoprenaline and atropine should be administered;
- Temporary PM implantation should be considered;
- After recovery from the COVID-19 infection the need for permanent PM implantation should be reassessed.
10. Treatment of SARS-CoV-2 infection
- There is a scarcity of evidence regarding the efficacy and risk of different treatment strategies in patients with COVID-19 disease;
- In all patients undergoing antiviral treatment, it is of major importance to correct modifiable predisposing factors to QTc prolongation: electrolyte imbalances, concomitant unnecessary drugs and bradycardia;
- Baseline ECGs may not be needed in all before starting antiviral treatment, especially if recent prior ECGs are available and no clinical indication (like unexplained syncope). This saves HCP time and reduces nosocomial spread;
- On-treatment ECGs are recommended to rule out significant prolongation of QTc (> 500 ms, or by > 60 ms versus baseline);
- Resource allocation will need to be adjusted locally depending on availability and demand. According to the context, it is worth exploring alternative ECG monitoring methods (e.g. monitoring leads, smartphone-enabled mobile ECG, handheld devices);
- In COVID-19 patients with an indication for oral anticoagulant therapy, renal and liver function and drug-drug interactions between oral anticoagulant and COVID-19 therapies should be considered in order to minimize the risk of bleeding or thromboembolic complications;
- In NOAC-eligible patients (i.e. those without mechanical prosthetic heart valves, moderate to severe mitral stenosis or antiphospholipid syndrome), NOACs are preferred over VKAs owing to their better safety and fixed dosing without the need for laboratory monitoring of anticoagulant effect (hence no direct contact), notwithstanding the importance of proper NOAC dosing and adherence to treatment;
- Whereas apixaban, rivaroxaban or edoxaban can be given as oral solutions or crushed tablets (via enteral tubes), severely ill COVID-19 patients may be switched to parenteral anticoagulation, which has no clinically relevant drug-drug interactions with COVID-19 therapies (with the exception of azithromycin, which should not be co-administered with UFH).
10.1. Arrhythmogenic and QTc Considerations of COVID-19 Therapies
Treatment strategies against SARS-CoV‑2 potentially use a combination of several drugs exerting synergistic effects. Despite the lack of definitive evidence on their efficacy, drugs with suspected viricide effect that are being used ‘off-label’ include chloroquine/hydroxychloroquine, protease inhibitors (like lopinavir-ritonavir or, in a minority of cases, darunavir-cobicistat), remdesivir and azithromycin.217-220 In specific cases, interferon and, for the ARDS glucocorticoids and/or tocilizumab, may also be administered.221
Chloroquine has been widely used as an antimalarial drug and in the treatment of rheumatological diseases like systemic lupus erythematosus and rheumatoid arthritis, and has been found to inhibit SARS-CoV‑2 growth in vitro.218-220 Hydroxychloroquine is an analogue of chloroquine with less gastric intolerance and less concerns for drug interactions. In vitro, hydroxychloroquine was found to be more potent than chloroquine in inhibiting SARS-CoV‑2.220 A recent small clinical study reported that SARS-CoV‑2 positivity in nasopharyngeal secretions is significantly decreased at day 6 after inclusion (i.e. day 10 after symptom onset) in hydroxychloroquine-treated COVID-19 patients (n = 26) versus patients who received supportive care only (n = 16). However, several major limitations (small sample size; non-homogeneous groups with differences in viral loads, number of days since onset of symptoms and quality of follow-up; and rather late administration of the drug, close to the expected time of viral clearance), raise doubts about the significance of the findings.218 The current evidence therefore does not imply yet a translation of (hydroxy)chloroquine in vitro activity to clinically relevant outcomes. Results of ongoing clinical trials of chloroquine/hydroxychloroquine efficacy in the treatment of SARS-CoV‑2 should be awaited before definite recommendations are provided for or against the use of these drugs. One major concern with these drugs is the very rare risk of QTc prolongation and TdP/sudden death. A recent metanalysis on arrhythmogenic cardiotoxicity of the quinolines and structurally related antimalarial drugs suggested that this risk is minimal (no events of SCD or documented VF of TdP in 35 448 individuals, 1207 of whom were taking chloroquine).222 However, during COVID-19 infection, the QT-related risk may be amplified by concomitant use of other QTc-prolonging drugs and/or electrolyte imbalances (hypokalaemia, hypomagnesaemia and/or hypocalcaemia). A second concern with chloroquine/hydroxychloroquine is the potential occurrence of conduction disturbances, although these are rare and appear to be linked mostly to long-term treatment (Table 15).
The protease inhibitor lopinavir-ritonavir has shown to be effective against SARS-coronavirus and MERS-coronavirus in vitro and in animal models.223-226 A recent randomized controlled open-label trial suggested that in hospitalized patients with severe COVID-19, lopinavir-ritonavir combined therapy does not provide additional benefit to standard of care.227 The main criticism of this study is the delayed time from illness onset to treatment assignment (median 13 days). Importantly, no pro-arrhythmic major adverse events were described in either arm and there was only one QTc prolongation in the lopinavir ritonavir arm (no details on the degree or the existence of other concomitant QTc prolonging factors).227 However, important drug-drug interactions have been described (mainly because these potent CYP3A4 inhibitors interfere with (hydroxy)chloroquine metabolism) that should be taken into consideration. In some combinations, dose adjustments or changes may be needed (Table 15). When lopinavir-ritonavir is not available and/or the patient is intolerant, darunavir-cobicistat is used as an alternative.
In vitro and animal studies suggest that remdesivir (GS-5734) is effective against zoonotic and epidemic SARS-coronavirus and MERS-coronavirus.228-230 Several randomized controlled studies are underway in the current SARS-CoV‑2 epidemic. In vitro studies suggest a better efficacy of remdesivir compared to lopinavir-ritonavir.230 An advantage of remdesivir is that no significant drug interactions have been described. However, there are no reports on its effect on QTc duration. Unfortunately, currently it is not widely available worldwide (only in clinical trials or for compassionate use from Gilead Sciences, Inc.).
The anecdotal evidence supporting the use of azithromycin (being a weak CYP3A4 inhibitor) comes from the above-mentioned open-label small non-randomized study of hydroxychloroquine treated COVID-19 patients (n = 26) versus patients who received supportive care only (n = 16). In 6 patients, the addition of azithromycin to hydroxychloroquine showed significant SARS-CoV‑2 positivity reduction in nasopharyngeal secretions compared to hydroxychloroquine alone.218 Azithromycin has in isolated cases been associated with QTc prolongation and TdP mainly in individuals with additional risk factors.231,232 Two studies have evaluated the association of chloroquine and azithromycin for the prevention and treatment for malaria in Africa with 114 and 1445 individuals, respectively in the arm treated with the combination.233,234 The association of chloroquine and azithromycin showed an acceptable safety profile.
For a detailed overview of all known direct or indirect (through drug-drug interactions) arrhythmological effects of experimental pharmacological therapies in COVID-19 patients, see Table 15.
10.1.1. QTc Evaluation to Prevent Drug-Induced Pro-Arrhythmia
QTc prolongation by some drugs can theoretically lead to polymorphic VT (TdP). This is however a very rare complication, and the consideration has to be balanced versus the anticipated benefit of therapy for the COVID-19 patient. Figure 19 provides a practical flow chart for the management of patients to prevent TdP, for guidance on the timing and repetition of ECG recording, and on QTc measurements that would alter therapy. Other guidance flowcharts have been published.213, 262 Briefly, the following steps are required to reduce the risk of drug induced TdP:
- Identify risk factors associated with QTc prolongation;
- Non-modifiable risk factors: congenital LQTS, known QT prolongation on QT prolonging drugs, female sex, age > 65 years, structural heart disease (ACS, uncompensated HF, hypertrophic cardiomyopathy), renal impairment, liver impairment;
- Modifiable risk factors: hypocalcaemia, hypokalaemia, hypomagnesaemia, concomitant use of QTc-prolonging medications and bradycardia;
- Identify and correct modifiable risk factors in all patients. Serum potassium should be kept at the high end (≥ 4.5 mEq/L);263
- Perform a baseline ECG (12-lead or single strip depending on resource availability). Patients with a baseline QTc ≥ 500 ms are at risk of developing TdP or sudden death. The risk-benefit of treatment in this group should be carefully assessed. In some patients with a recent ECG showing normal QTc and no evidence of major CV alterations due to COVID-19, one may consider not to take a baseline ECG since every ECG exposes HCP and may contaminate equipment;
- Perform an ECG once on treatment. If the patient has a QTc ≥ 500 ms or shows a ∆QTc ≥ 60 ms, consideration should be given to either switching to a drug with a lower risk of QTc prolongation, reducing the dose administered, or continuing the treatment plan. Close surveillance of the QTc (preferably including telemetry for arrhythmia monitoring) and electrolyte balance are mandatory.
Bradycardia prolongs QT and facilitates TdP. While some COVID-19 drugs have a weak bradycardic effect, the concomitant use of beta-blockers, CCBs, ivabradine and digoxin should also be evaluated. If digoxin is considered mandatory for the patient, plasma level monitoring should be considered (with ensuing dose reduction if needed).
10.1.2. Technical Aspects of QT Measurements
For patients with wide QRS complex (≥ 120 ms) due to bundle branch block or ventricular pacing, QTc adjustment is needed. Formulae are available, but a simpler approach may be to use a QTc cut off of 550 ms instead of 500 ms. Others propose a rule of thumb to calculate QT minus (QRS width 100 ms).
A standard 12-lead ECG may not always be easy to obtain, given the enormous burden of increasing numbers of COVID-19 patients on healthcare providers. Enhanced use of modern handheld ECG devices should be considered in order to reduce traditional ECG recording as much as possible to preserve resources and limit virus spread. In a recent study, the QTc in lead‐I and lead‐II derived from a standard 12-lead ECG was compared with a rhythm strip from a handheld ECG device in 99 healthy volunteers and 20 hospitalized patients in sinus rhythm treated with dofetilide or sotalol.264 QT on the handheld device had an excellent agreement with standard 12‐lead ECG both in the normal range and in patients with QT prolongation.264 This handheld ECG device (KardiaMobile 6L Alivecor) had a high specificity for detecting a QTc > 450 ms and should thus be considered as an effective outpatient tool for monitoring patients with prolonged QTc. Recently, KardiaMobile6L received expedited approval from the FDA for QT monitoring and can thus be used in COVID-19 patients treated with QT prolonging drugs such as chloroquine or hydroxychloroquine.
10.2. Considerations on the Use of Anticoagulants in COVID-19 Patients
Many cardiac patients or patients with other CV history will have an indication for anticoagulation. Table 16 lists the possible interactions of COVID-19 therapies with VKAs, NOACs, LMWHs and UFH. The table includes information that was derived from several drug interaction sites, which have been referenced. Drug SmPCs often do not contain information for older drugs and/or drugs with a narrow spectrum of indications (like chloroquine). Antimalarial drugs have a P-glycoprotein inhibiting effect, which may affect NOAC plasma levels. COVID-19 patients on oral anticoagulation may be switched over to parenteral anticoagulation with LMWH and UFH when admitted to an ICU with a severe clinical presentation.
We would like to rephrase here also the conventional dose reduction criteria for NOACs, for those patients in whom oral treatment for stroke prevention in AF patients, can be continued. For more details, including the assessment of renal (and liver) function and other considerations in patients taking a NOAC, please see the 2018 EHRA Practical Guide on the use of NOACs in patients with AF.265 Of note, none of the NOACs is recommended in patients with a creatinine clearance (CrCl) <15 ml/min according to the EU label.
- Apixaban: the standard dose (2 x 5 mg) should be reduced to 2 x 2.5 mg if two out of three criteria are met (body weight ≤ 60 kg, age ≥ 80 years, serum creatinine ≥ 133 µmol/l [1.5 mg/dL]), or if the CrCl is 15–29 mL/min;
- Dabigatran: the standard doses 2 x 150 mg and 2 x 110 mg. No pre-specified dose reduction criteria but, per the drug label, 2 x 110 mg should be used if age > 80 years, concomitant verapamil, increased risk of gastrointestinal bleeding;
- Edoxaban: the standard dose (1 x 60 mg) should be reduced to 1 x 30 mg if weight < 60 kg, CrCl < 50 mL/min, concomitant therapy with a strong P-gp inhibitor;
- Rivaroxaban: the standard dose (1 x 20 mg) should be reduced to 1 x 15mg if CrCl < 50 mL/min.
For patients with impaired swallowing, NOACs can be administered in the following ways:
- Administration in a crushed form (e.g. via a nasogastric tube) does not alter the bioavailability of apixaban, edoxaban and rivaroxaban;266-268
- Apixaban can be given as oral solution or via nasogastric or gastric tube on an empty stomach (food impairs bioavailability of the crushed tablets);269
- Rivaroxaban tablet can either be crushed and mixed in water or apple puree and taken orally, or suspended in water and given via nasogastric tube (enteral tubes must not be distal to the stomach) followed by food;267
- Dabigatran capsules must not be opened, as it would result in a 75% increase in the drug bioavailability.269
11. Patient Information
There are many pending questions about the COVID-19 pandemic.274 What is the full spectrum of disease severity? How is the transmissibility? What is the role of asymptomatic/pre-symptomatic infected persons? How long is the virus present? What are the risk factors for severe illness? Knowledge is being accumulated very fast and our task is to deliver key information for patients with CVD.
- Patient information is of paramount importance during the COVID-19 pandemic when the allocation of medical resources is a matter of debate;275
- Pre-existing CVD has a direct impact on the risk of SARS-CoV‑2 and survival;21
- The occurrence of SARS may lead to CV complications as well as treatments used to cure the COVID-19 disease;
- Unambiguous information to the population and the patients is key for a better control of the disease and the rapid development of specific treatment strategies.
11.1. Who is at Risk for Severe SARS-CoV-2?
There are several clinical features associated worse short-term outcome of SARS-CoV‑2 manifestations.54 These include asthma, age > 65-year-old, COPD, chronic HF, cardiac arrythmias, coronary artery disease. Female sex, statin therapy or ACE inhibitors appear to be independent protective factors. The effect of social background and ethnicity on survival needs some clarification. A cause-and-effect relationship between drug therapy and survival should not be inferred given the lack of ongoing randomized trials. Patients should be informed and take appropriate precautions with emphasis on measures for social distancing when the potential risk is high and medical resources are scarce.
11.2. My Treatment During the COVID-19 Pandemic?
- COVID-19 disease may trigger destabilization of chronic CVD. This may be also favoured by chronic oral treatment interruption and patients should be informed to seek medical guidance prior to any treatment modifications;
- Aspirin dosage given for the secondary prevention of atherothrombosis has no anti inflammatory potential and therefore should not been interrupted in COVID-19 patients without any other relevant reasons such as ongoing bleeding complication or the need for an unplanned invasive procedure;
- Many patients at potential risk for SARS-CoV‑2 are treated with inhibitors of the RAS including ACEIs. ACE2 facilitates coronavirus entry into cells but is not inhibited by ACEIs or Ang II type 1 receptor blockers or upregulated by these treatments. For these reasons, patients should not discontinue their treatments without medical guidance;52,191
- There are some treatments that may need to be adjusted when concomitant specific therapy for the COVID-19 disease is initiated. These treatments are initiated during hospital admission and potential drug-drug interactions are summarized in Table 17 and Table 18.
11.3. Interactions with Others, Healthy Lifestyle and Medical Advice during COVID-19 Pandemic
The following information is important for individuals with CVD:
- Interaction with others:
- Avoid people who are sick;
- Keep a two-metre distance from other individuals whenever possible;
- Wash hands thoroughly with soap and warm water for at least 20 seconds;
- Cover the mouth or nose when you cough or sneeze with a tissue or use the inside of the elbow;
- Avoid touching the eyes, nose and mouth;
- To remove the virus, often clean surfaces like doorknobs or handles with a disinfectant;
- Self-isolate in case of symptoms of fever, cough or a chest infection;
- Stay home as much as possible;
- Maintain physical activity to avoid VTE and maintain well-being.
Additionally, individuals should be encouraged to follow the instruction of the Department of Health and local authorities in the resident countries as these may differ.
Maintain a healthy lifestyle (e.g. eat healthy, quit smoking, restrict alcohol intake, get adequate sleep and keep physically active).276 Isolation and physical restrictions may lead to inactivity and increased risk of VTE, in combination with co-morbidities. Physical activity should be strongly encouraged either in a home setting or outdoor areas with social space and will also improve well-being. Maintaining social network should be encouraged remotely.
- Medical advice:
- Continue with prescribed medication for CVD;
- Seek medical help immediately if experiencing symptoms such as chest pain. Do not neglect symptoms;
- Do not interrupt cardiac follow-up and seek advice of a cardiologist promptly in case of deterioration of the CV condition.
- Andreini, Daniele
Centro Cardiologico Monzino, IRCCS, Milano
Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
- Arbelo, Elena
Arrhythmia Section, Cardiology Department, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain
IDIBAPS, Institut d’Investigació August Pi i Sunyer (IDIBAPS), Barcelona, Spain
Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
ECGen, the Cardiogenetics Focus Group of EHRA
- Barbato, Emanuele
Dipartimento di Scienze Biomediche Avanzate, Università degli Studi "Federico II", Napoli, Italy
- Bartorelli, Antonio L
Department of Clinical Sciences and Community HealthDepartment of Biomedical and Clinical Sciences “Luigi Sacco”, University of Milan, Milan, Italy
Centro Cardiologico Monzino, IRCCS, Milan, Italy
- Baumbach, Andreas
Centre for Cardiovascular Medicine and Devices, William Harvey Research Institute, Queen Mary University of London and Barts Heart Centre, London, United Kingdom
Yale University School of Medicine, New Haven, USA
- Behr, Elijah R
Cardiology Clinical Academic Group, Institute of Molecular and Clinical Sciences, St George’s, University of London and St George’s University Hospitals NHS Foundation Trust, London United Kingdom. European Reference Network for Rare and Low Prevalence Complex Diseases of the Heart (ERN GUARDHEART; http://guardheart.ern-net.eu). ECGen, the Cardiogenetics Focus Group of EHRA
- Berti, Sergio
U.O.C. Cardiologia Diagnostica e Interventistica, Dipartimento Cardiotoracico, Fondazione Toscana G. Monasterio - Ospedale del Cuore G. Pasquinucci, Massa, Italy
- Capodanno, Davide
Division of Cardiology, A.O.U. "Policlinico G. Rodolico-San Marco" University of Catania, Catania, Italy
- Cappato, Riccardo
Arrhythmia and Electrophysiology Research Center, Humanitas Clinical and Research Center, Rozzano, Italy
- Chieffo, Alaide
Interventional Cardiology Unit, San Raffaele Hospital, Milan, Italy
- Collet, Jean-Philippe
Sorbonne Université, ACTION study group, UMR_S 1166, Institut de Cardiologie, Pitié Salpêtrière Hospital (AP-HP), Paris, France
- Cuisset, Thomas
Département de Cardiologie, CHU Timone, Marseille F-13385, France
INSERM, UMR1062, Nutrition, Obesity and Risk of Thrombosis, Marseille F-13385, France
Faculté de Médecine, Aix-Marseille Université, Marseille F-13385, France
- Delgado, Victoria
Heart Lung Centrum, Leiden University Medical Center, Leiden, The Netherlands
- Dendale, Paul
Heart Centre Hasselt, Jessa Hospital, Hasselt, Belgium
UHasselt, Faculty of Medicine and Life Sciences, Agoralaan, 3590 Diepenbeek, Belgium
- de Simone, Giovanni
Hypertension Research Center, Federico II University Hospital, Naples, Italy
- Dudek, Dariusz
2nd Department of Cardiology and Cardiovascular Interventions, University Hospital, 31-501 Kraków, Poland
Department of Interventional Cardiology, Jagiellonian University Medical College, 31-202 Kraków, Poland
- Edvardsen, Thor
Department of Cardiology Oslo University Hospital, Rikshospitalet, Sognsvannsveien 20, NO-0372 Oslo, Norway PO Box 4950 Nydalen, NO-0424 Oslo, Norway
- Elvan, Arif
Isala Heart Center, Zwolle, The Netherlands
- Gilard, Martine
Département de cardiologie, Hôpital Universitaire La Cavale Blanche, Brest, France
- Gori, Mauro
Cardiovascular Department & Cardiology Unit, Papa Giovanni XXIII Hospital-Bergamo, Bergamo Italy
- Grobbee, Diederick
Julius Global Health, the Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, the Netherlands
- Guzik, Tomasz J
Institute of Cardiovascular and Medical Sciences, University of Glasgow, 120 University Place, Glasgow G12 8TA, United Kingdom
Department of Medicine, Jagiellonian University College of Medicine, Krakow, Poland
- Halvorsen, Sigrun
Department of Cardiology, Oslo University Hospital Ulleval and University of Oslo, Oslo, Norway
- Hansen, Tina B
Department of Cardiology, Zealand University Hospital, Roskilde, Denmark
University of Southern Denmark, Department of Regional Health Research, Odense, Denmark
- Haude, Michael
Medical Clinic I, Städtische Kliniken Neuss, Lukaskrankenhaus GmbH, Germany (M.H.)
- Heidbüchel, Hein
Department of Cardiology, University Hospital and University Antwerp, Antwerp, Belgium
- Hindricks, Gerhard
Department of Internal Medicine/Cardiology/Electrophysiology, Heart Center Leipzig, University Hospital, and Leipzig Heart Institute (LHI), Leipzig, Germany
- Ibanez, Borja
Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain; CIBER de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
IIS-Fundación Jiménez Díaz Hospital, Madrid, Spain
- Karam, Nicole
Université de Paris, PARCC, INSERM, F-75015, European Hospital Georges Pompidou, Paris, France
- Katus, Hugo
Department of Cardiology, Angiology and Pneumology, Heidelberg University Hospital, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
- Klok, Fredrikus A
Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
- Konstantinides, Stavros V
Center for Thrombosis and Hemostasis, Johannes Gutenberg University Mainz, Building 403, Langenbeckstr. 1, 55131 Mainz, Germany
Department of Cardiology, Democritus University of Thrace, 68100 Alexandroupolis, Greece
- Landmesser, Ulf
Department of Cardiology, Charite University Medicine Berlin, Berlin, Germany
Berlin Institute of Health (BIH); German Center of Cardiovascular Research (DZHK); Partner Site Berlin, Berlin, Germany
- Leclercq, Christophe
University of Rennes, CHU Rennes, INSERM, LTSI - UMR 1099, F-35000, Rennes, France
- Leonardi, Sergio
University of Pavia Pavia, and Fondazione IRCCS Policlinico S.Matteo Italy
- Lettino, Maddalena
Cardio-Thoracic and Vascular Department, San Gerardo Hospital, ASST-Monza, Monza, Italy
- Marenzi Giancarlo
Centro Cardiologico Monzino, IRCCS, Milan, Italy
- Mauri, Josepa
Interventional Cardiology Unit. Cardiology Department Hospital Universitari Germans Trias I Pujol. Badalona. Spain
Health Department of the Government of Catalonia, Barcelona, Spain
- Metra, Marco
Institute of Cardiology, ASST Spedali Civili di Brescia; Department of Medical and Surgical Specialities, Radiological Sciences and Publich Health, University of Brescia, Brescia, Italy
- Morici, Nuccia
Unità di Cure Intensive Cardiologiche e De Gasperis Cardio Center, ASST Grande Ospedale Metropolitano Niguarda, Milano - Dipartimento di Scienze Cliniche e di Comunità, Università degli Studi, Milano, Italy
- Mueller, Christian
Cardiovascular Research Institute Basel, University Hospital Basel, University of Basel, Basel, Switzerland
- Petronio, Anna Sonia
Cardiothoracic and Vascular Department, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
- Potpara, Tatjana
School of Medicine, Belgrade University, Belgrade, Serbia
Cardiology Clinic, Clinical Centre of Serbia, Dr Subotica 13, Belgrade, Serbia
- Praz, Fabien
Department of Cardiology, University Hospital Bern, Bern, Switzerland
- Prendergast, Bernard
Bernard Prendergast, St Thomas' Hospital and Cleveland Clinic London, United Kingdom
- Prescott, Eva
Center for Cardiovascular Research, Bispebjerg Frederiksberg Hospital, University of Copenhagen, Copenhagen, Denmark
- Price, Susanna
Royal Brompton and Harefield NHS Foundation Trust, Royal Brompton Hospital, London, United Kingdom
- Pruszczyk, Piotr
Department of Internal Medicine & Cardiology, Medical University of Warsaw, Lindleya 4 St., 02-005 Warsaw, Poland
- Roffi, Marco
Department of Cardiology, Geneva University Hospitals; Geneva-Switzerland
- Rosenkranz, Stephan
Clinic III for Internal Medicine (Cardiology) and Cologne Cardiovascular Research Center (CCRC), Heart Center at the University of Cologne, Germany (S.R.)
Center for Molecular Medicine Cologne (CMMC), University of Cologne, Germany (S.R.)
- Sarkozy, Andrea
Department of Cardiology, University Hospital Antwerp, University of Antwerp, Antwerp, Belgium
- Scherrenberg, Martijn
Heart Centre Hasselt, Jessa Hospital, Hasselt, Belgium
UHasselt, Faculty of Medicine and Life Sciences, Agoralaan, 3590 Diepenbeek, Belgium
- Seferovic, Petar
Faculty of Medicine, University of Belgrade, Serbia. 2. Serbian Academy of Sciences and Arts, Serbia
- Senni, Michele
Cardiovascular Department & Cardiology Unit, Papa Giovanni XXIII Hospital-Bergamo, Bergamo, Italy
- Spera, Francesco R
Department of Cardiology, University Hospital Antwerp, University of Antwerp, Antwerp, Belgium
- Stefanini, Giulio
Cardio Center, Humanitas Clinical and Research Hospital IRCCS, Rozzano-Milan, Italy
- Thiele, Holger
Department of Internal Medicine/Cardiology, Heart Center Leipzig at University of Leipzig, Leipzig, Germany
- Torracca, Lucia
Cardiac Surgery Department, Humanitas University Hospital, Rozzano, Milano, Italy
- Touyz, Rhian M
Institute of Cardiovascular and Medical Sciences, University of Glasgow, 120 University Place, Glasgow G12 8TA, United Kingdom
- Wilde, Arthur
Amsterdam UMC, University of Amsterdam, Heart Center; department of Cardiology, Amsterdam, The Netherlands
European Reference Network for Rare and Low Prevalence Complex Diseases of the Heart (ERN GUARDHEART)
ECGen, the Cardiogenetics Focus Group of EHRA
- Williams, Bryan
Institute of Cardiovascular Science, University College London (UCL), London, United Kingdom
University College London Hospitals, London, United Kingdom
- Windecker, Stephan
Department of Cardiology, Bern University Hospital, Inselspital, University of Bern, Bern, Switzerland
- Aboyans, Victor
UMR 1094 INSERM, Limoges University, Limoges, France
Department of cardiology, Limoges University Hospital, Limoges, France
- Anker, Stefan D
Department of Cardiology (CVK); and Berlin Institute of Health Center for Regenerative Therapies (BCRT), German Center for Cardiovascular Research (DZHK) partner site Berlin; Charité Universitätsmedizin Berlin, Berlin, Germany
- Baigent, Colin
MRC Population Health Research Unit, Nuffield Department of Population Health, Oxford, United Kingdom
- Byrne, Robert A.
Dublin Cardiovascular Research Institute, Mater Private Hospital, Dublin, Ireland; and School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland
- Camm, A. John
St George's University of London, United Kingdom
- Coats, Andrew J. Stewart
San Raffaele Pisana Scientific Institute, Rome, Italy
- de Boer, Rudolf A.
University of Groningen, University Medical Center Groningen, Department of Cardiology, Groningen, The Netherlands
- Dimmeler, Stefanie
Institute for Cardiovascular Regeneration, Goethe University Frankfurt, Germany
German Center for Cardiovascular Research DZHK, Berlin, Germany, partner site Frankfurt Rhine-Main, Germany
Cardiopulmonary Institute, Goethe University Frankfurt, Germany
- Fitzsimons, Donna
School of Nursing & Midwifery, Queen's University Belfast, Faculty of Medicine Life and Health Science, Belfast, UNITED KINGDOM
- Gräni, Christoph
Department of Cardiology Bern University Hospital Bern Switzerland
- Hamm, Christian
University of Giessen, Campus Kerckhoff, Heart and Thorax Center, Bad Nauheim, Germany
- Iung, Bernard
Cardiology Department, Bichat Hospital, APHP, Paris, France
Université de Paris, France
- Kastrati, Adnan
Deutsches Herzzentrum München, Technische Universität, and the German Centre for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance, Germany
- Lancellotti, Patrizio
Department of Cardiology, GIGA Cardiovascular Sciences, University of Liège Hospital, Heart Valve Clinic, CHU Sart Tilman, CHU Sart Tilman, 4000 Liège, Belgium
- Mehilli, Julinda
University Hospital Munich, Ludwig-Maximilians University and
German Centre for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance, both in Munich, Germany
- Merkely, Béla
Heart and Vascular Center, Semmelweis University, Budapest, Hungary
- Neubeck, Lis
School of Health and Social Care, Edinburgh Napier University, Edinburgh, United Kingdom
- Odening, Katja E.
Translational Cardiology, Department of Cardiology, Inselspital, University Hospital Bern, and Department of Physiology, University of Bern, Bern, Switzerland
Department of Cardiology and Angiology I, Heart Center University of Freiburg, Faculty of Medicine, Freiburg, Germany
- Piccolo, Raffaele
Division of Cardiology, Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
- Räber, Lorenz
Department of Cardiology, Bern University Hospital, University of Bern, Bern, Switzerland
- Reichlin, Tobias
Department of Cardiology, Inselpstial, Bern University Hospital, University of Bern, Bern, Switzerland
- Sabate, Manel
Interventional Cardiology Department, Cardiovascular Institute, Hospital Clinic, University of Barcelona, Barcelona, Spain
- Schulze, P. Christian
Department of Internal Medicine I, Jena University Hospital, Friedrich Schiller University, Jena, Germany
- Simpson, Iain A.
University Hospital Southampton, Southampton. United Kingdom
- Søndergaard, Lars
The Heart Center, Rigshospitalet, Copenhagen, Denmark
- Sousa-Uva, Miguel
Department of Cardiac Surgery, Hospital Santa Cruz, Lisbon, Portugal and Department of Surgery and Physiology, Cardiovascular Research Centre, Faculty of Medicine, Porto University, Porto
- Stortecky, Stefan
Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Tchétché, Didier
Clinique Pasteur, Toulouse, France
- Zeppenfeld, Katja
Department of Cardiology, Leiden University Medical Center, Leiden, the Netherlands
15. List of Reference
- Dong E, Du H, Gardner L. An interactive web-based dashboard to track COVID-19 in real time. Lancet Infect Dis 2020;20(5):533-534. https://doi.org/10.1016/S1473-3099(20)30120-1
- Clerkin KJ, Fried JA, Raikhelkar J, Sayer G, Griffin JM, Masoumi A, Jain SS, Burkhoff D, Kumaraiah D, Rabbani L, Schwartz A, Uriel N. COVID-19 and Cardiovascular Disease. Circulation 2020;141(20):1648-1655. https://doi.org/10.1161/CIRCULATIONAHA.120.046941
- Wu J, A. M, Katz J, Peltier E. 74,000 missing deaths: Tracking the true toll of the coronavirus outbreak. https://nyti.ms/34QerxA (May 13, 2020; date last accessed).
- Epidemiology Working Group for Ncip Epidemic Response CCfDC, Prevention. [The epidemiological characteristics of an outbreak of 2019 novel coronavirus diseases (COVID-19) in China]. Zhonghua Liu Xing Bing Xue Za Zhi 2020;41(2):145-151. https://doi.org/10.3760/cma.j.issn.0254-6450.2020.02.003
- Zhao D, Liu J, Wang M, Zhang X, Zhou M. Epidemiology of cardiovascular disease in China: current features and implications. Nat Rev Cardiol 2019;16(4):203-212. https://doi.org/10.1038/s41569-018-0119-4
- Richardson S, Hirsch JS, Narasimhan M, Crawford JM, McGinn T, Davidson KW, and the Northwell C-RC, Barnaby DP, Becker LB, Chelico JD, Cohen SL, Cookingham J, Coppa K, Diefenbach MA, Dominello AJ, Duer-Hefele J, Falzon L, Gitlin J, Hajizadeh N, Harvin TG, Hirschwerk DA, Kim EJ, Kozel ZM, Marrast LM, Mogavero JN, Osorio GA, Qiu M, Zanos TP. Presenting Characteristics, Comorbidities, and Outcomes Among 5700 Patients Hospitalized With COVID-19 in the New York City Area. JAMA 2020. https://doi.org/10.1001/jama.2020.6775
- Center for Disease Control and Prevention. Hypertension statistics and maps. https://www.cdc.gov/bloodpressure/statistics_maps.htm.
- Center for Disease Control and Prevention. Diabetes data and statistics. https://www.cdc.gov/diabetes/data/index.html.
- Center for Disease Control and Prevention. Overweight & obesity - data & statistics. https://www.cdc.gov/obesity/data/index.html.
- Wang D, Hu B, Hu C, Zhu F, Liu X, Zhang J, Wang B, Xiang H, Cheng Z, Xiong Y, Zhao Y, Li Y, Wang X, Peng Z. Clinical Characteristics of 138 Hospitalized Patients With 2019 Novel Coronavirus-Infected Pneumonia in Wuhan, China. JAMA 2020. https://doi.org/10.1001/jama.2020.1585
- Khunti K, Singh AK, Pareek M, Hanif W. Is ethnicity linked to incidence or outcomes of covid-19? BMJ 2020;369:m1548. https://doi.org/10.1136/bmj.m1548
- Resnick A, Galea S, Sivashanker K. Covid-19: The painful price of ignoring health inequities. https://blogs.bmj.com/bmj/2020/03/18/covid-19-the-painful-price-of-ignoring-health-inequities/ (March 18, 2020; date last accessed).
- Intensive Care National Audit and Research Centre. ICNARC report on COVID-19 in critical care. 01 May 2020. https://www.icnarc.org/Our-Audit/Audits/Cmp/Reports (May 1, 2020; date last accessed).
- Simpson CR, Steiner MF, Cezard G, Bansal N, Fischbacher C, Douglas A, Bhopal R, Sheikh A, researchers S. Ethnic variations in morbidity and mortality from lower respiratory tract infections: a retrospective cohort study. J R Soc Med 2015;108(10):406-17. https://doi.org/10.1177/0141076815588321
- Martineau AR, Jolliffe DA, Hooper RL, Greenberg L, Aloia JF, Bergman P, Dubnov-Raz G, Esposito S, Ganmaa D, Ginde AA, Goodall EC, Grant CC, Griffiths CJ, Janssens W, Laaksi I, Manaseki-Holland S, Mauger D, Murdoch DR, Neale R, Rees JR, Simpson S, Jr., Stelmach I, Kumar GT, Urashima M, Camargo CA, Jr. Vitamin D supplementation to prevent acute respiratory tract infections: systematic review and meta-analysis of individual participant data. BMJ 2017;356:i6583. https://doi.org/10.1136/bmj.i6583
- Miller A, Reandelar MJ, Fasciglione K, Roumenova V, Li Y, Otazu GH. Correlation between universal BCG vaccination policy and reduced morbidity and mortality for COVID-19: an epidemiological study. MedRxiv 2020. https://doi.org/10.1101/2020.03.24.20042937
- Verity R, Okell LC, Dorigatti I, Winskill P, Whittaker C, Imai N, Cuomo-Dannenburg G, Thompson H, Walker PGT, Fu H, Dighe A, Griffin JT, Baguelin M, Bhatia S, Boonyasiri A, Cori A, Cucunuba Z, FitzJohn R, Gaythorpe K, Green W, Hamlet A, Hinsley W, Laydon D, Nedjati-Gilani G, Riley S, van Elsland S, Volz E, Wang H, Wang Y, Xi X, Donnelly CA, Ghani AC, Ferguson NM. Estimates of the severity of coronavirus disease 2019: a model-based analysis. Lancet Infect Dis 2020. https://doi.org/10.1016/S1473-3099(20)30243-7
- Onder G, Rezza G, Brusaferro S. Case-Fatality Rate and Characteristics of Patients Dying in Relation to COVID-19 in Italy. JAMA 2020. https://doi.org/10.1001/jama.2020.4683
- Wu Z, McGoogan JM. Characteristics of and Important Lessons From the Coronavirus Disease 2019 (COVID-19) Outbreak in China: Summary of a Report of 72314 Cases From the Chinese Center for Disease Control and Prevention. JAMA 2020. https://doi.org/10.1001/jama.2020.2648
- Driggin E, Madhavan MV, Bikdeli B, Chuich T, Laracy J, Biondi-Zoccai G, Brown TS, Der Nigoghossian C, Zidar DA, Haythe J, Brodie D, Beckman JA, Kirtane AJ, Stone GW, Krumholz HM, Parikh SA. Cardiovascular Considerations for Patients, Health Care Workers, and Health Systems During the COVID-19 Pandemic. J Am Coll Cardiol 2020;75(18):2352-2371. https://doi.org/10.1016/j.jacc.2020.03.031
- Zheng YY, Ma YT, Zhang JY, Xie X. COVID-19 and the cardiovascular system. Nat Rev Cardiol 2020;17(5):259-260. https://doi.org/10.1038/s41569-020-0360-5
- Xiong TY, Redwood S, Prendergast B, Chen M. Coronaviruses and the cardiovascular system: acute and long-term implications. Eur Heart J 2020;41(19):1798-1800. https://doi.org/10.1093/eurheartj/ehaa231
- Yu CM, Wong RS, Wu EB, Kong SL, Wong J, Yip GW, Soo YO, Chiu ML, Chan YS, Hui D, Lee N, Wu A, Leung CB, Sung JJ. Cardiovascular complications of severe acute respiratory syndrome. Postgrad Med J 2006;82(964):140-4. https://doi.org/10.1136/pgmj.2005.037515
- Xu Z, Shi L, Wang Y, Zhang J, Huang L, Zhang C, Liu S, Zhao P, Liu H, Zhu L, Tai Y, Bai C, Gao T, Song J, Xia P, Dong J, Zhao J, Wang FS. Pathological findings of COVID-19 associated with acute respiratory distress syndrome. Lancet Respir Med 2020;8(4):420-422. https://doi.org/10.1016/S2213-2600(20)30076-X
- Guo T, Fan Y, Chen M, Wu X, Zhang L, He T, Wang H, Wan J, Wang X, Lu Z. Cardiovascular Implications of Fatal Outcomes of Patients With Coronavirus Disease 2019 (COVID-19). JAMA Cardiol 2020. https://doi.org/10.1001/jamacardio.2020.1017
- Shi S, Qin M, Shen B, Cai Y, Liu T, Yang F, Gong W, Liu X, Liang J, Zhao Q, Huang H, Yang B, Huang C. Association of Cardiac Injury With Mortality in Hospitalized Patients With COVID-19 in Wuhan, China. JAMA Cardiol 2020. https://doi.org/10.1001/jamacardio.2020.0950
- Madjid M, Safavi-Naeini P, Solomon SD, Vardeny O. Potential Effects of Coronaviruses on the Cardiovascular System: A Review. JAMA Cardiol 2020. https://doi.org/10.1001/jamacardio.2020.1286
- Cui J, Li F, Shi ZL. Origin and evolution of pathogenic coronaviruses. Nat Rev Microbiol 2019;17(3):181-192. https://doi.org/10.1038/s41579-018-0118-9
- Zhou P, Yang XL, Wang XG, Hu B, Zhang L, Zhang W, Si HR, Zhu Y, Li B, Huang CL, Chen HD, Chen J, Luo Y, Guo H, Jiang RD, Liu MQ, Chen Y, Shen XR, Wang X, Zheng XS, Zhao K, Chen QJ, Deng F, Liu LL, Yan B, Zhan FX, Wang YY, Xiao GF, Shi ZL. A pneumonia outbreak associated with a new coronavirus of probable bat origin. Nature 2020;579(7798):270-273. https://doi.org/10.1038/s41586-020-2012-7
- van Doremalen N, Bushmaker T, Morris DH, Holbrook MG, Gamble A, Williamson BN, Tamin A, Harcourt JL, Thornburg NJ, Gerber SI, Lloyd-Smith JO, de Wit E, Munster VJ. Aerosol and Surface Stability of SARS-CoV-2 as Compared with SARS-CoV-1. N Engl J Med 2020;382(16):1564-1567. https://doi.org/10.1056/NEJMc2004973
- Zhao S, Lin Q, Ran J, Musa SS, Yang G, Wang W, Lou Y, Gao D, Yang L, He D, Wang MH. Preliminary estimation of the basic reproduction number of novel coronavirus (2019-nCoV) in China, from 2019 to 2020: A data-driven analysis in the early phase of the outbreak. Int J Infect Dis 2020;92:214-217. https://doi.org/10.1016/j.ijid.2020.01.050
- Guo YR, Cao QD, Hong ZS, Tan YY, Chen SD, Jin HJ, Tan KS, Wang DY, Yan Y. The origin, transmission and clinical therapies on coronavirus disease 2019 (COVID-19) outbreak - an update on the status. Mil Med Res 2020;7(1):11. https://doi.org/10.1186/s40779-020-00240-0
- Liu Y, Yang Y, Zhang C, Huang F, Wang F, Yuan J, Wang Z, Li J, Li J, Feng C, Zhang Z, Wang L, Peng L, Chen L, Qin Y, Zhao D, Tan S, Yin L, Xu J, Zhou C, Jiang C, Liu L. Clinical and biochemical indexes from 2019-nCoV infected patients linked to viral loads and lung injury. Sci China Life Sci 2020;63(3):364-374. https://doi.org/10.1007/s11427-020-1643-8
- Zhou F, Yu T, Du R, Fan G, Liu Y, Liu Z, Xiang J, Wang Y, Song B, Gu X, Guan L, Wei Y, Li H, Wu X, Xu J, Tu S, Zhang Y, Chen H, Cao B. Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study. Lancet 2020;395(10229):1054-1062. https://doi.org/10.1016/S0140-6736(20)30566-3
- Walls AC, Park YJ, Tortorici MA, Wall A, McGuire AT, Veesler D. Structure, Function, and Antigenicity of the SARS-CoV-2 Spike Glycoprotein. Cell 2020;181(2):281-292 e6. https://doi.org/10.1016/j.cell.2020.02.058
- Yan R, Zhang Y, Li Y, Xia L, Guo Y, Zhou Q. Structural basis for the recognition of SARS-CoV-2 by full-length human ACE2. Science 2020;367(6485):1444-1448. https://doi.org/10.1126/science.abb2762
- Santos RAS, Sampaio WO, Alzamora AC, Motta-Santos D, Alenina N, Bader M, Campagnole-Santos MJ. The ACE2/Angiotensin-(1-7)/MAS Axis of the Renin-Angiotensin System: Focus on Angiotensin-(1-7). Physiol Rev 2018;98(1):505-553. https://doi.org/10.1152/physrev.00023.2016
- Li W, Moore MJ, Vasilieva N, Sui J, Wong SK, Berne MA, Somasundaran M, Sullivan JL, Luzuriaga K, Greenough TC, Choe H, Farzan M. Angiotensin-converting enzyme 2 is a functional receptor for the SARS coronavirus. Nature 2003;426(6965):450-4. https://doi.org/10.1038/nature02145
- Hoffmann M, Kleine-Weber H, Schroeder S, Kruger N, Herrler T, Erichsen S, Schiergens TS, Herrler G, Wu NH, Nitsche A, Muller MA, Drosten C, Pohlmann S. SARS-CoV-2 Cell Entry Depends on ACE2 and TMPRSS2 and Is Blocked by a Clinically Proven Protease Inhibitor. Cell 2020;181(2):271-280 e8. https://doi.org/10.1016/j.cell.2020.02.052
- Wu Y. Compensation of ACE2 Function for Possible Clinical Management of 2019-nCoV-Induced Acute Lung Injury. Virol Sin 2020. https://doi.org/10.1007/s12250-020-00205-6
- Hamming I, Timens W, Bulthuis ML, Lely AT, Navis G, van Goor H. Tissue distribution of ACE2 protein, the functional receptor for SARS coronavirus. A first step in understanding SARS pathogenesis. J Pathol 2004;203(2):631-7. https://doi.org/10.1002/path.1570
- Zou X, Chen K, Zou J, Han P, Hao J, Han Z. Single-cell RNA-seq data analysis on the receptor ACE2 expression reveals the potential risk of different human organs vulnerable to 2019-nCoV infection. Front Med 2020;14(2):185-192. https://doi.org/10.1007/s11684-020-0754-0
- Guzik TJ, Mohiddin SA, Dimarco A, Patel V, Savvatis K, Marelli-Berg FM, Madhur MS, Tomaszewski M, Maffia P, D'Acquisto F, Nicklin SA, Marian AJ, Nosalski R, Murray EC, Guzik B, Berry C, Touyz RM, Kreutz R, Wang DW, Bhella D, Sagliocco O, Crea F, Thomson EC, McInnes IB. COVID-19 and the cardiovascular system: implications for risk assessment, diagnosis, and treatment options. Cardiovasc Res 2020;In press. https://doi.org/10.1093/cvr/cvaa106
- Chen C, Zhou Y, Wang DW. SARS-CoV-2: a potential novel etiology of fulminant myocarditis. Herz 2020;45(3):230-232. https://doi.org/10.1007/s00059-020-04909-z
- Chen L, Li X, Chen M, Feng Y, Xiong C. The ACE2 expression in human heart indicates new potential mechanism of heart injury among patients infected with SARS-CoV-2. Cardiovasc Res 2020;116(6):1097-1100. https://doi.org/10.1093/cvr/cvaa078
- Fang L, Karakiulakis G, Roth M. Are patients with hypertension and diabetes mellitus at increased risk for COVID-19 infection? Lancet Respir Med 2020;8(4):e21. https://doi.org/10.1016/S2213-2600(20)30116-8
- Williams B, Zhang Y. Hypertension, renin-angiotensin-aldosterone system inhibition, and COVID-19. Lancet 2020. https://doi.org/10.1016/S0140-6736(20)31131-4
- Kuster GM, Pfister O, Burkard T, Zhou Q, Twerenbold R, Haaf P, Widmer AF, Osswald S. SARS-CoV2: should inhibitors of the renin-angiotensin system be withdrawn in patients with COVID-19? Eur Heart J 2020;41(19):1801-1803. https://doi.org/10.1093/eurheartj/ehaa235
- Ferrario CM, Jessup J, Chappell MC, Averill DB, Brosnihan KB, Tallant EA, Diz DI, Gallagher PE. Effect of angiotensin-converting enzyme inhibition and angiotensin II receptor blockers on cardiac angiotensin-converting enzyme 2. Circulation 2005;111(20):2605-10. https://doi.org/10.1161/CIRCULATIONAHA.104.510461
- Deshotels MR, Xia H, Sriramula S, Lazartigues E, Filipeanu CM. Angiotensin II mediates angiotensin converting enzyme type 2 internalization and degradation through an angiotensin II type I receptor-dependent mechanism. Hypertension 2014;64(6):1368-1375. https://doi.org/10.1161/HYPERTENSIONAHA.114.03743
- Vaduganathan M, Vardeny O, Michel T, McMurray JJV, Pfeffer MA, Solomon SD. Renin-Angiotensin-Aldosterone System Inhibitors in Patients with Covid-19. N Engl J Med 2020;382(17):1653-1659. https://doi.org/10.1056/NEJMsr2005760
- Danser AHJ, Epstein M, Batlle D. Renin-Angiotensin System Blockers and the COVID-19 Pandemic: At Present There Is No Evidence to Abandon Renin-Angiotensin System Blockers. Hypertension 2020;75(6):1382-1385. https://doi.org/10.1161/HYPERTENSIONAHA.120.15082
- Sun ML, Yang JM, Sun YP, Su GH. [Inhibitors of RAS Might Be a Good Choice for the Therapy of COVID-19 Pneumonia]. Zhonghua Jie He He Hu Xi Za Zhi 2020;43(3):219-222. https://doi.org/10.3760/cma.j.issn.1001-0939.2020.03.016
- Mehra MR, Desai SS, Kuy S, Henry TD, Patel AN. Cardiovascular Disease, Drug Therapy, and Mortality in Covid-19. N Engl J Med 2020. https://doi.org/10.1056/NEJMoa2007621
- Bean D, Kraljevic Z, Searle T, Bendayan R, Pickles A, Folarin A, Roguski L, Noor K, Shek A, o'gallagher K, Zakeri R, Shah A, Teo J, Dobson RJB. Treatment with ACE-inhibitors is associated with less severe disease with SARS-Covid-19 infection in a multi-site UK acute Hospital Trust. medRxiv 2020. https://doi.org/10.1101/2020.04.07.20056788
- de Abajo FJ, Rodríguez-Martín S, Lerma V, Mejía-Abril G, Aguilar M, García-Luque A, Laredo L, Laosa O, Centeno-Soto GA, Gálvez MÁ. Use of renin–angiotensin–aldosterone system inhibitors and risk of COVID-19 requiring admission to hospital: a case-population study. The Lancet 2020.
- Li J, Wang X, Chen J, Zhang H, Deng A. Association of Renin-Angiotensin System Inhibitors With Severity or Risk of Death in Patients With Hypertension Hospitalized for Coronavirus Disease 2019 (COVID-19) Infection in Wuhan, China. JAMA Cardiol 2020. https://doi.org/10.1001/jamacardio.2020.1624
- Mancia G, Rea F, Ludergnani M, Apolone G, Corrao G. Renin-Angiotensin-Aldosterone System Blockers and the Risk of Covid-19. N Engl J Med 2020. https://doi.org/10.1056/NEJMoa2006923
- Reynolds HR, Adhikari S, Pulgarin C, Troxel AB, Iturrate E, Johnson SB, Hausvater A, Newman JD, Berger JS, Bangalore S, Katz SD, Fishman GI, Kunichoff D, Chen Y, Ogedegbe G, Hochman JS. Renin-Angiotensin-Aldosterone System Inhibitors and Risk of Covid-19. N Engl J Med 2020. https://doi.org/10.1056/NEJMoa2008975
- Zhang P, Zhu L, Cai J, Lei F, Qin JJ, Xie J, Liu YM, Zhao YC, Huang X, Lin L, Xia M, Chen MM, Cheng X, Zhang X, Guo D, Peng Y, Ji YX, Chen J, She ZG, Wang Y, Xu Q, Tan R, Wang H, Lin J, Luo P, Fu S, Cai H, Ye P, Xiao B, Mao W, Liu L, Yan Y, Liu M, Chen M, Zhang XJ, Wang X, Touyz RM, Xia J, Zhang BH, Huang X, Yuan Y, Rohit L, Liu PP, Li H. Association of Inpatient Use of Angiotensin Converting Enzyme Inhibitors and Angiotensin II Receptor Blockers with Mortality Among Patients With Hypertension Hospitalized With COVID-19. Circ Res 2020. https://doi.org/10.1161/CIRCRESAHA.120.317134
- Inciardi RM, Lupi L, Zaccone G, Italia L, Raffo M, Tomasoni D, Cani DS, Cerini M, Farina D, Gavazzi E, Maroldi R, Adamo M, Ammirati E, Sinagra G, Lombardi CM, Metra M. Cardiac Involvement in a Patient With Coronavirus Disease 2019 (COVID-19). JAMA Cardiol 2020. https://doi.org/10.1001/jamacardio.2020.1096
- Drummond GR, Vinh A, Guzik TJ, Sobey CG. Immune mechanisms of hypertension. Nat Rev Immunol 2019;19(8):517-532. https://doi.org/10.1038/s41577-019-0160-5
- Maffia P, Guzik TJ. When, where, and how to target vascular inflammation in the post-CANTOS era? Eur Heart J 2019;40(30):2492-2494. https://doi.org/10.1093/eurheartj/ehz133
- Li Z, Guo X, Hao W, Wu Y, Ji Y, Zhao Y, Liu F, Xie X. The relationship between serum interleukins and T-lymphocyte subsets in patients with severe acute respiratory syndrome. Chinese medical journal 2003;116:981-4.
- Huang C, Wang Y, Li X, Ren L, Zhao J, Hu Y, Zhang L, Fan G, Xu J, Gu X, Cheng Z, Yu T, Xia J, Wei Y, Wu W, Xie X, Yin W, Li H, Liu M, Xiao Y, Gao H, Guo L, Xie J, Wang G, Jiang R, Gao Z, Jin Q, Wang J, Cao B. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet 2020;395(10223):497-506. https://doi.org/10.1016/S0140-6736(20)30183-5
- Ruan Q, Yang K, Wang W, Jiang L, Song J. Clinical predictors of mortality due to COVID-19 based on an analysis of data of 150 patients from Wuhan, China. Intensive Care Med 2020;46(5):846-848. https://doi.org/10.1007/s00134-020-05991-x
- Siedlinski M, Jozefczuk E, Xu X, Teumer A, Evangelou E, Schnabel RB, Welsh P, Maffia P, Erdmann J, Tomaszewski M, Caulfield MJ, Sattar N, Holmes MV, Guzik TJ. White Blood Cells and Blood Pressure: A Mendelian Randomization Study. Circulation 2020;141(16):1307-1317. https://doi.org/10.1161/CIRCULATIONAHA.119.045102
- Youn JC, Yu HT, Lim BJ, Koh MJ, Lee J, Chang DY, Choi YS, Lee SH, Kang SM, Jang Y, Yoo OJ, Shin EC, Park S. Immunosenescent CD8+ T cells and C-X-C chemokine receptor type 3 chemokines are increased in human hypertension. Hypertension 2013;62(1):126-33. https://doi.org/10.1161/HYPERTENSIONAHA.113.00689
- Chan JF, Yip CC, To KK, Tang TH, Wong SC, Leung KH, Fung AY, Ng AC, Zou Z, Tsoi HW, Choi GK, Tam AR, Cheng VC, Chan KH, Tsang OT, Yuen KY. Improved Molecular Diagnosis of COVID-19 by the Novel, Highly Sensitive and Specific COVID-19-RdRp/Hel Real-Time Reverse Transcription-PCR Assay Validated In Vitro and with Clinical Specimens. J Clin Microbiol 2020;58(5). https://doi.org/10.1128/JCM.00310-20
- China National Health Commission. National health commission of the people’s republic of China. Chinese clinical guidance for covid-19 pneumonia diagnosis and treatment (7th edition). http://kjfy.meetingchina.org/msite/news/show/cn/3337.html (March 16, 2020; date last accessed).
- World Health Organization. Laboratory testing for coronavirus disease 2019 (COVID-19) in suspected human cases: interim guidance, 2 March 2020. https://apps.who.int/iris/handle/10665/331329 (2020; date last accessed).
- Ai T, Yang Z, Hou H, Zhan C, Chen C, Lv W, Tao Q, Sun Z, Xia L. Correlation of Chest CT and RT-PCR Testing in Coronavirus Disease 2019 (COVID-19) in China: A Report of 1014 Cases. Radiology 2020:200642. https://doi.org/10.1148/radiol.2020200642
- World Health Organization. Global surveillance for COVID-19 caused by human infection with COVID-19 virus: interim guidance, 20 March 2020. https://extranet.who.int/iris/restricted/handle/10665/331506 (2020; date last accessed).
- Center for Disease Control and Prevention. Coronavirus (COVID-19). https://www.cdc.gov/coronavirus/2019-nCoV/index.html.
- European Centre for Disease Prevention and Control. ECDC technical report- Infection prevention and control for COVID-19 in healthcare settings - first update 12 March 2020 https://www.ecdc.europa.eu/sites/default/files/documents/COVID-19-infection-prevention-and-control-healthcare-settings-march-2020.pdf (March 12, 2020; date last accessed).
- Cheng X. Protecting cardiologists during the COVID-19 epidemic – lessons from Wuhan, China. https://www.escardio.org/Education/COVID-19-and-Cardiology/protecting-cardiologists-during-the-covid-19-epidemic-lessons-from-wuhan (March 26, 2020; date last accessed).
- Liang T. Handbook of COVID-19 Prevention and Treatment; 2020. https://gmcc.alibabadoctor.com/prevention-manual/detail?content_id=0.
- Luo M, Cao S, Wei L, Tang R, Hong S, Liu R, Wang Y. Precautions for Intubating Patients with COVID-19. Anesthesiology 2020;132(6):1616-1618. https://doi.org/10.1097/ALN.0000000000003288
- Center for Disease Control and Prevention. Coronavirus disease 2019 (COVID-19) - symptoms of coronavirus. https://www.cdc.gov/coronavirus/2019-ncov/symptoms-testing/symptoms.html (March 20, 2020; date last accessed).
- Guan WJ, Ni ZY, Hu Y, Liang WH, Ou CQ, He JX, Liu L, Shan H, Lei CL, Hui DSC, Du B, Li LJ, Zeng G, Yuen KY, Chen RC, Tang CL, Wang T, Chen PY, Xiang J, Li SY, Wang JL, Liang ZJ, Peng YX, Wei L, Liu Y, Hu YH, Peng P, Wang JM, Liu JY, Chen Z, Li G, Zheng ZJ, Qiu SQ, Luo J, Ye CJ, Zhu SY, Zhong NS, China Medical Treatment Expert Group for C. Clinical Characteristics of Coronavirus Disease 2019 in China. N Engl J Med 2020;382(18):1708-1720. https://doi.org/10.1056/NEJMoa2002032
- World Health Organization. Advice on the use of masks in the context of COVID-19. https://www.who.int/publications-detail/advice-on-the-use-of-masks-in-the-community-during-home-care-and-in-healthcare-settings-in-the-context-of-the-novel-coronavirus-(2019-ncov)-outbreak (April 6, 2020; date last accessed).
- Shi H, Han X, Jiang N, Cao Y, Alwalid O, Gu J, Fan Y, Zheng C. Radiological findings from 81 patients with COVID-19 pneumonia in Wuhan, China: a descriptive study. Lancet Infect Dis 2020;20(4):425-434. https://doi.org/10.1016/S1473-3099(20)30086-4
- Zeng J, Huang J, Pan L. How to balance acute myocardial infarction and COVID-19: the protocols from Sichuan Provincial People's Hospital. Intensive Care Med 2020. https://doi.org/10.1007/s00134-020-05993-9
- Chen N, Zhou M, Dong X, Qu J, Gong F, Han Y, Qiu Y, Wang J, Liu Y, Wei Y, Xia J, Yu T, Zhang X, Zhang L. Epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in Wuhan, China: a descriptive study. Lancet 2020;395(10223):507-513. https://doi.org/10.1016/S0140-6736(20)30211-7
- Lee IK, Wang CC, Lin MC, Kung CT, Lan KC, Lee CT. Effective strategies to prevent coronavirus disease-2019 (COVID-19) outbreak in hospital. J Hosp Infect 2020;105(1):102-103. https://doi.org/10.1016/j.jhin.2020.02.022
- Hollander JE, Carr BG. Virtually Perfect? Telemedicine for Covid-19. N Engl J Med 2020;382(18):1679-1681. https://doi.org/10.1056/NEJMp2003539
- Nacoti M, Ciocca A, Giupponi A, Brambillasca P, Lussana F, Pisano M, Goisis G, Bonacina D, Fazzi F, Naspro R, Longhi L, Cereda M, Montaguti C. At the epicenter of the COVID-19 pandemic and humanitarian crises in Italy: changing perspectives on preparation and mitigation. Catalyst non-issue content 2020;1(2). https://doi.org/10.1056/CAT.20.0080
- Rombola G, Heidempergher M, Pedrini L, Farina M, Aucella F, Messa P, Brunori G. Practical indications for the prevention and management of SARS-CoV-2 in ambulatory dialysis patients: lessons from the first phase of the epidemics in Lombardy. J Nephrol 2020;33(2):193-196. https://doi.org/10.1007/s40620-020-00727-y
- Arentz M, Yim E, Klaff L, Lokhandwala S, Riedo FX, Chong M, Lee M. Characteristics and Outcomes of 21 Critically Ill Patients With COVID-19 in Washington State. JAMA 2020. https://doi.org/10.1001/jama.2020.4326
- Vergano M, Bertolini G, Giannini A, Gristina G, Livigni S, Mistraletti G, Petrini F. Clinical Ethics Recommendations for the Allocation of Intensive Care Treatments in exceptional, resource-limited circumstances - Version n. 1. http://www.siaarti.it/SiteAssets/News/COVID19%20-%20documenti%20SIAARTI/SIAARTI%20-%20Covid-19%20-%20Clinical%20Ethics%20Reccomendations.pdf (Mar 16, 2020; date last accessed).
- Regione Lombardia. Coronavirus – Ultimi provvedimenti. https://www.regione.lombardia.it/wps/portal/istituzionale/HP/DettaglioRedazionale/servizi-e-informazioni/cittadini/salute-e-prevenzione/Prevenzione-e-benessere/red-coronavirusnuoviaggiornamenti (March 30, 2020; date last accessed).
- Grasselli G, Pesenti A, Cecconi M. Critical Care Utilization for the COVID-19 Outbreak in Lombardy, Italy: Early Experience and Forecast During an Emergency Response. JAMA 2020. https://doi.org/10.1001/jama.2020.4031
- National Health Committee of the People's Republic of China. Notice of the general office of the national health and health commission on printing and distributing the work plan for the transport of pneumonia cases with new coronavirus infection (trial). http://www.nhc.gov.cn/yzygj/s7653p/202001/ccee6ec0942a42a18df8e5ce6329b6f5.shtml (January 27, 2020; date last accessed).
- Han Y, Zeng H, Jiang H, Yang Y, Yuan Z, Cheng X, Jing Z, Liu B, Chen J, Nie S, Zhu J, Li F, Ma C. CSC Expert Consensus on Principles of Clinical Management of Patients With Severe Emergent Cardiovascular Diseases During the COVID-19 Epidemic. Circulation 2020;141(20):e810-e816. https://doi.org/10.1161/CIRCULATIONAHA.120.047011
- Porcheddu R, Serra C, Kelvin D, Kelvin N, Rubino S. Similarity in Case Fatality Rates (CFR) of COVID-19/SARS-COV-2 in Italy and China. J Infect Dev Ctries 2020;14(2):125-128. https://doi.org/10.3855/jidc.12600
- Biddison LD, Berkowitz KA, Courtney B, De Jong CM, Devereaux AV, Kissoon N, Roxland BE, Sprung CL, Dichter JR, Christian MD, Powell T, Task Force for Mass Critical C, Task Force for Mass Critical C. Ethical considerations: care of the critically ill and injured during pandemics and disasters: CHEST consensus statement. Chest 2014;146(4 Suppl):e145S-55S. https://doi.org/10.1378/chest.14-0742
- World Health Organization. COVID 19: Occupational Health. https://www.who.int/news-room/detail/09-03-2020-covid-19-occupational-health (March 9, 2020; date last accessed).
- Bonnefoy-Cudraz E, Bueno H, Casella G, De Maria E, Fitzsimons D, Halvorsen S, Hassager C, Iakobishvili Z, Magdy A, Marandi T, Mimoso J, Parkhomenko A, Price S, Rokyta R, Roubille F, Serpytis P, Shimony A, Stepinska J, Tint D, Trendafilova E, Tubaro M, Vrints C, Walker D, Zahger D, Zima E, Zukermann R, Lettino M. Editor's Choice - Acute Cardiovascular Care Association Position Paper on Intensive Cardiovascular Care Units: An update on their definition, structure, organisation and function. Eur Heart J Acute Cardiovasc Care 2018;7(1):80-95. https://doi.org/10.1177/2048872617724269
- Wu C, Chen X, Cai Y, Xia J, Zhou X, Xu S, Huang H, Zhang L, Zhou X, Du C, Zhang Y, Song J, Wang S, Chao Y, Yang Z, Xu J, Zhou X, Chen D, Xiong W, Xu L, Zhou F, Jiang J, Bai C, Zheng J, Song Y. Risk Factors Associated With Acute Respiratory Distress Syndrome and Death in Patients With Coronavirus Disease 2019 Pneumonia in Wuhan, China. JAMA Intern Med 2020. https://doi.org/10.1001/jamainternmed.2020.0994
- Ferguson ND, Fan E, Camporota L, Antonelli M, Anzueto A, Beale R, Brochard L, Brower R, Esteban A, Gattinoni L, Rhodes A, Slutsky AS, Vincent JL, Rubenfeld GD, Thompson BT, Ranieri VM. The Berlin definition of ARDS: an expanded rationale, justification, and supplementary material. Intensive Care Med 2012;38(10):1573-82. https://doi.org/10.1007/s00134-012-2682-1
- Thiele H, Ohman EM, de Waha-Thiele S, Zeymer U, Desch S. Management of cardiogenic shock complicating myocardial infarction: an update 2019. Eur Heart J 2019;40(32):2671-2683. https://doi.org/10.1093/eurheartj/ehz363
- Yang X, Yu Y, Xu J, Shu H, Xia J, Liu H, Wu Y, Zhang L, Yu Z, Fang M, Yu T, Wang Y, Pan S, Zou X, Yuan S, Shang Y. Clinical course and outcomes of critically ill patients with SARS-CoV-2 pneumonia in Wuhan, China: a single-centered, retrospective, observational study. Lancet Respir Med 2020;8(5):475-481. https://doi.org/10.1016/S2213-2600(20)30079-5
- Baran DA, Grines CL, Bailey S, Burkhoff D, Hall SA, Henry TD, Hollenberg SM, Kapur NK, O'Neill W, Ornato JP, Stelling K, Thiele H, van Diepen S, Naidu SS. SCAI clinical expert consensus statement on the classification of cardiogenic shock: This document was endorsed by the American College of Cardiology (ACC), the American Heart Association (AHA), the Society of Critical Care Medicine (SCCM), and the Society of Thoracic Surgeons (STS) in April 2019. Catheter Cardiovasc Interv 2019;94(1):29-37. https://doi.org/10.1002/ccd.28329
- Hu H, Ma F, Wei X, Fang Y. Coronavirus fulminant myocarditis saved with glucocorticoid and human immunoglobulin. Eur Heart J 2020. https://doi.org/10.1093/eurheartj/ehaa190
- Corrales-Medina VF, Alvarez KN, Weissfeld LA, Angus DC, Chirinos JA, Chang CC, Newman A, Loehr L, Folsom AR, Elkind MS, Lyles MF, Kronmal RA, Yende S. Association between hospitalization for pneumonia and subsequent risk of cardiovascular disease. JAMA 2015;313(3):264-74. https://doi.org/10.1001/jama.2014.18229
- Corrales-Medina VF, Musher DM, Wells GA, Chirinos JA, Chen L, Fine MJ. Cardiac complications in patients with community-acquired pneumonia: incidence, timing, risk factors, and association with short-term mortality. Circulation 2012;125(6):773-81. https://doi.org/10.1161/CIRCULATIONAHA.111.040766
- Kwong JC, Li P, Redelmeier DA. Influenza morbidity and mortality in elderly patients receiving statins: a cohort study. PLoS One 2009;4(11):e8087. https://doi.org/10.1371/journal.pone.0008087
- Musher DM, Abers MS, Corrales-Medina VF. Acute Infection and Myocardial Infarction. N Engl J Med 2019;380(2):171-176. https://doi.org/10.1056/NEJMra1808137
- Madjid M, Miller CC, Zarubaev VV, Marinich IG, Kiselev OI, Lobzin YV, Filippov AE, Casscells SW, 3rd. Influenza epidemics and acute respiratory disease activity are associated with a surge in autopsy-confirmed coronary heart disease death: results from 8 years of autopsies in 34,892 subjects. Eur Heart J 2007;28(10):1205-10. https://doi.org/10.1093/eurheartj/ehm035
- Peiris JS, Chu CM, Cheng VC, Chan KS, Hung IF, Poon LL, Law KI, Tang BS, Hon TY, Chan CS, Chan KH, Ng JS, Zheng BJ, Ng WL, Lai RW, Guan Y, Yuen KY, Group HUSS. Clinical progression and viral load in a community outbreak of coronavirus-associated SARS pneumonia: a prospective study. Lancet 2003;361(9371):1767-72. https://doi.org/10.1016/s0140-6736(03)13412-5
- Gao C, Wang Y, Gu X, Shen X, Zhou D, Zhou S, Huang JA, Cao B, Guo Q, Community-Acquired Pneumonia-China N. Association Between Cardiac Injury and Mortality in Hospitalized Patients Infected With Avian Influenza A (H7N9) Virus. Crit Care Med 2020;48(4):451-458. https://doi.org/10.1097/CCM.0000000000004207
- Flores F, Walter J, Wussler D, Kozhuharov N, Nowak A, Dinort J, Badertscher P, Martin J, Sabti Z, du Fay de Lavallaz J, Nestelberger T, Boeddinghaus J, Zimmermann T, Koechlin L, Glatz B, Czmok R, Michou E, Gualandro DM, Breidthardt T, Mueller C. Direct comparison of high-sensitivity cardiac troponin t and i for prediction of mortality in patients with pneumonia. J Clin Chem Lab Med 2019;2(2):1000131.
- Roffi M, Patrono C, Collet JP, Mueller C, Valgimigli M, Andreotti F, Bax JJ, Borger MA, Brotons C, Chew DP, Gencer B, Hasenfuss G, Kjeldsen K, Lancellotti P, Landmesser U, Mehilli J, Mukherjee D, Storey RF, Windecker S, Group ESCSD. 2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation: Task Force for the Management of Acute Coronary Syndromes in Patients Presenting without Persistent ST-Segment Elevation of the European Society of Cardiology (ESC). Eur Heart J 2016;37(3):267-315. https://doi.org/10.1093/eurheartj/ehv320
- Ibanez B, James S, Agewall S, Antunes MJ, Bucciarelli-Ducci C, Bueno H, Caforio ALP, Crea F, Goudevenos JA, Halvorsen S, Hindricks G, Kastrati A, Lenzen MJ, Prescott E, Roffi M, Valgimigli M, Varenhorst C, Vranckx P, Widimsky P, Group ESCSD. 2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation: The Task Force for the management of acute myocardial infarction in patients presenting with ST-segment elevation of the European Society of Cardiology (ESC). Eur Heart J 2018;39(2):119-177. https://doi.org/10.1093/eurheartj/ehx393
- Christ-Crain M, Breidthardt T, Stolz D, Zobrist K, Bingisser R, Miedinger D, Leuppi J, Tamm M, Mueller B, Mueller C. Use of B-type natriuretic peptide in the risk stratification of community-acquired pneumonia. J Intern Med 2008;264(2):166-76. https://doi.org/10.1111/j.1365-2796.2008.01934.x
- Mueller C, Laule-Kilian K, Frana B, Rodriguez D, Scholer A, Schindler C, Perruchoud AP. Use of B-type natriuretic peptide in the management of acute dyspnea in patients with pulmonary disease. Am Heart J 2006;151(2):471-7. https://doi.org/10.1016/j.ahj.2005.03.036
- Mueller C, McDonald K, de Boer RA, Maisel A, Cleland JGF, Kozhuharov N, Coats AJS, Metra M, Mebazaa A, Ruschitzka F, Lainscak M, Filippatos G, Seferovic PM, Meijers WC, Bayes-Genis A, Mueller T, Richards M, Januzzi JL, Jr., Heart Failure Association of the European Society of C. Heart Failure Association of the European Society of Cardiology practical guidance on the use of natriuretic peptide concentrations. Eur J Heart Fail 2019;21(6):715-731. https://doi.org/10.1002/ejhf.1494
- Giannitsis E, Mair J, Christersson C, Siegbahn A, Huber K, Jaffe AS, Peacock WF, Plebani M, Thygesen K, Mockel M, Mueller C, Lindahl B, Biomarker Study Group of the European Society of Cardiology Acute Cardiovascular Care A. How to use D-dimer in acute cardiovascular care. Eur Heart J Acute Cardiovasc Care 2017;6(1):69-80. https://doi.org/10.1177/2048872615610870
- Konstantinides SV, Meyer G, Becattini C, Bueno H, Geersing GJ, Harjola VP, Huisman MV, Humbert M, Jennings CS, Jimenez D, Kucher N, Lang IM, Lankeit M, Lorusso R, Mazzolai L, Meneveau N, Ainle FN, Prandoni P, Pruszczyk P, Righini M, Torbicki A, Van Belle E, Zamorano JL, The Task Force for the d, management of acute pulmonary embolism of the European Society of C. 2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the European Respiratory Society (ERS): The Task Force for the diagnosis and management of acute pulmonary embolism of the European Society of Cardiology (ESC). Eur Respir J 2019;54(3). https://doi.org/10.1183/13993003.01647-2019
- Kearon C, de Wit K, Parpia S, Schulman S, Afilalo M, Hirsch A, Spencer FA, Sharma S, D'Aragon F, Deshaies JF, Le Gal G, Lazo-Langner A, Wu C, Rudd-Scott L, Bates SM, Julian JA, Investigators PES. Diagnosis of Pulmonary Embolism with d-Dimer Adjusted to Clinical Probability. N Engl J Med 2019;381(22):2125-2134. https://doi.org/10.1056/NEJMoa1909159
- van der Hulle T, Cheung WY, Kooij S, Beenen LFM, van Bemmel T, van Es J, Faber LM, Hazelaar GM, Heringhaus C, Hofstee H, Hovens MMC, Kaasjager KAH, van Klink RCJ, Kruip M, Loeffen RF, Mairuhu ATA, Middeldorp S, Nijkeuter M, van der Pol LM, Schol-Gelok S, Ten Wolde M, Klok FA, Huisman MV, group Ys. Simplified diagnostic management of suspected pulmonary embolism (the YEARS study): a prospective, multicentre, cohort study. Lancet 2017;390(10091):289-297. https://doi.org/10.1016/S0140-6736(17)30885-1
- van der Pol LM, Tromeur C, Bistervels IM, Ni Ainle F, van Bemmel T, Bertoletti L, Couturaud F, van Dooren YPA, Elias A, Faber LM, Hofstee HMA, van der Hulle T, Kruip M, Maignan M, Mairuhu ATA, Middeldorp S, Nijkeuter M, Roy PM, Sanchez O, Schmidt J, Ten Wolde M, Klok FA, Huisman MV, Artemis Study I. Pregnancy-Adapted YEARS Algorithm for Diagnosis of Suspected Pulmonary Embolism. N Engl J Med 2019;380(12):1139-1149. https://doi.org/10.1056/NEJMoa1813865
- Patel AB, Verma A. COVID-19 and Angiotensin-Converting Enzyme Inhibitors and Angiotensin Receptor Blockers: What Is the Evidence? JAMA 2020. https://doi.org/10.1001/jama.2020.4812
- Boeddinghaus J, Nestelberger T, Twerenbold R, Neumann JT, Lindahl B, Giannitsis E, Sorensen NA, Badertscher P, Jann JE, Wussler D, Puelacher C, Rubini Gimenez M, Wildi K, Strebel I, Du Fay de Lavallaz J, Selman F, Sabti Z, Kozhuharov N, Potlukova E, Rentsch K, Miro O, Martin-Sanchez FJ, Morawiec B, Parenica J, Lohrmann J, Kloos W, Buser A, Geigy N, Keller DI, Osswald S, Reichlin T, Westermann D, Blankenberg S, Mueller C, Apace B, Investigators T-A. Impact of age on the performance of the ESC 0/1h-algorithms for early diagnosis of myocardial infarction. Eur Heart J 2018;39(42):3780-3794. https://doi.org/10.1093/eurheartj/ehy514
- Nestelberger T, Wildi K, Boeddinghaus J, Twerenbold R, Reichlin T, Gimenez MR, Puelacher C, Jaeger C, Grimm K, Sabti Z, Hillinger P, Kozhuharov N, du Fay de Lavallaz J, Pinck F, Lopez B, Salgado E, Miro O, Bingisser R, Lohrmann J, Osswald S, Mueller C. Characterization of the observe zone of the ESC 2015 high-sensitivity cardiac troponin 0h/1h-algorithm for the early diagnosis of acute myocardial infarction. Int J Cardiol 2016;207:238-45. https://doi.org/10.1016/j.ijcard.2016.01.112
- Twerenbold R, Badertscher P, Boeddinghaus J, Nestelberger T, Wildi K, Puelacher C, Sabti Z, Rubini Gimenez M, Tschirky S, du Fay de Lavallaz J, Kozhuharov N, Sazgary L, Mueller D, Breidthardt T, Strebel I, Flores Widmer D, Shrestha S, Miro O, Martin-Sanchez FJ, Morawiec B, Parenica J, Geigy N, Keller DI, Rentsch K, von Eckardstein A, Osswald S, Reichlin T, Mueller C. 0/1-Hour Triage Algorithm for Myocardial Infarction in Patients With Renal Dysfunction. Circulation 2018;137(5):436-451. https://doi.org/10.1161/CIRCULATIONAHA.117.028901
- Gluckman TJ. General guidance on deferring non-urgent cv testing and procedures during the COVID-19 pandemic. (March 24, 2020; date last accessed).
- Skulstad H, Cosyns B, Popescu BA, Galderisi M, Salvo GD, Donal E, Petersen S, Gimelli A, Haugaa KH, Muraru D, Almeida AG, Schulz-Menger J, Dweck MR, Pontone G, Sade LE, Gerber B, Maurovich-Horvat P, Bharucha T, Cameli M, Magne J, Westwood M, Maurer G, Edvardsen T. COVID-19 pandemic and cardiac imaging: EACVI recommendations on precautions, indications, prioritization, and protection for patients and healthcare personnel. Eur Heart J Cardiovasc Imaging 2020. https://doi.org/10.1093/ehjci/jeaa072
- Soldati G, Smargiassi A, Inchingolo R, Buonsenso D, Perrone T, Briganti DF, Perlini S, Torri E, Mariani A, Mossolani EE, Tursi F, Mento F, Demi L. Is There a Role for Lung Ultrasound During the COVID-19 Pandemic? J Ultrasound Med 2020. https://doi.org/10.1002/jum.15284
- Choi AD, Abbara S, Branch KR, Feuchtner GM, Ghoshhajra B, Nieman K, Pontone G, Villines TC, Williams MC, Blankstein R. Society of Cardiovascular Computed Tomography guidance for use of cardiac computed tomography amidst the COVID-19 pandemic Endorsed by the American College of Cardiology. J Cardiovasc Comput Tomogr 2020. https://doi.org/10.1016/j.jcct.2020.03.002
- American College of Cardiology. ACR recommendations for the use of chest radiography and computed tomography (ct) for suspected COVID-19 infection. https://www.acr.org/Advocacy-and-Economics/ACR-Position-Statements/Recommendations-for-Chest-Radiography-and-CT-for-Suspected-COVID19-Infection (March 22, 2020; date last accessed).
- Skali H, Murthy VL, Al-Mallah MH, Bateman TM, Beanlands R, Better N, Calnon DA, Dilsizian V, Gimelli A, Pagnanelli R, Polk DM, Soman P, Thompson RC, Einstein AJ, Dorbala S. Guidance and Best Practices for Nuclear Cardiology Laboratories during the Coronavirus Disease 2019 (COVID-19) Pandemic: An Information Statement from ASNC and SNMMI. Zenodo 2020;Preprint. https://doi.org/10.5281/zenodo.3738020
- Society for Cardiovascular Magnetic Resonance. SCMR’s covid-19 preparedness toolkit. https://scmr.org/page/COVID19 (March 25, 2020; date last accessed).
- Ferreira VM, Schulz-Menger J, Holmvang G, Kramer CM, Carbone I, Sechtem U, Kindermann I, Gutberlet M, Cooper LT, Liu P, Friedrich MG. Cardiovascular Magnetic Resonance in Nonischemic Myocardial Inflammation: Expert Recommendations. J Am Coll Cardiol 2018;72(24):3158-3176. https://doi.org/10.1016/j.jacc.2018.09.072
- Pieske B, Tschope C, de Boer RA, Fraser AG, Anker SD, Donal E, Edelmann F, Fu M, Guazzi M, Lam CSP, Lancellotti P, Melenovsky V, Morris DA, Nagel E, Pieske-Kraigher E, Ponikowski P, Solomon SD, Vasan RS, Rutten FH, Voors AA, Ruschitzka F, Paulus WJ, Seferovic P, Filippatos G. How to diagnose heart failure with preserved ejection fraction: the HFA-PEFF diagnostic algorithm: a consensus recommendation from the Heart Failure Association (HFA) of the European Society of Cardiology (ESC). Eur Heart J 2019;40(40):3297-3317. https://doi.org/10.1093/eurheartj/ehz641
- Stefanini GG, Azzolini E, Condorelli G. Critical Organizational Issues for Cardiologists in the COVID-19 Outbreak: A Frontline Experience From Milan, Italy. Circulation 2020;141(20):1597-1599. https://doi.org/10.1161/CIRCULATIONAHA.120.047070
- Neumann FJ, Sousa-Uva M, Ahlsson A, Alfonso F, Banning AP, Benedetto U, Byrne RA, Collet JP, Falk V, Head SJ, Juni P, Kastrati A, Koller A, Kristensen SD, Niebauer J, Richter DJ, Seferovic PM, Sibbing D, Stefanini GG, Windecker S, Yadav R, Zembala MO, Group ESCSD. 2018 ESC/EACTS Guidelines on myocardial revascularization. Eur Heart J 2019;40(2):87-165. https://doi.org/10.1093/eurheartj/ehy394
- Baumgartner H, Falk V, Bax JJ, De Bonis M, Hamm C, Holm PJ, Iung B, Lancellotti P, Lansac E, Rodriguez Munoz D, Rosenhek R, Sjogren J, Tornos Mas P, Vahanian A, Walther T, Wendler O, Windecker S, Zamorano JL, Group ESCSD. 2017 ESC/EACTS Guidelines for the management of valvular heart disease. Eur Heart J 2017;38(36):2739-2791. https://doi.org/10.1093/eurheartj/ehx391
- Kucharski AJ, Russell TW, Diamond C, Liu Y, Edmunds J, Funk S, Eggo RM, Centre for Mathematical Modelling of Infectious Diseases C-wg. Early dynamics of transmission and control of COVID-19: a mathematical modelling study. Lancet Infect Dis 2020;20(5):553-558. https://doi.org/10.1016/S1473-3099(20)30144-4
- Mebazaa A, Combes A, van Diepen S, Hollinger A, Katz JN, Landoni G, Hajjar LA, Lassus J, Lebreton G, Montalescot G, Park JJ, Price S, Sionis A, Yannopolos D, Harjola VP, Levy B, Thiele H. Management of cardiogenic shock complicating myocardial infarction. Intensive Care Med 2018;44(6):760-773. https://doi.org/10.1007/s00134-018-5214-9
- Perkins GD, Olasveengen TM, Maconochie I, Soar J, Wyllie J, Greif R, Lockey A, Semeraro F, Van de Voorde P, Lott C, Monsieurs KG, Nolan JP, European Resuscitation C. European Resuscitation Council Guidelines for Resuscitation: 2017 update. Resuscitation 2018;123:43-50. https://doi.org/10.1016/j.resuscitation.2017.12.007
- Christian MD, Hawryluck L, Wax RS, Cook T, Lazar NM, Herridge MS, Muller MP, Gowans DR, Fortier W, Burkle FM. Development of a triage protocol for critical care during an influenza pandemic. CMAJ 2006;175(11):1377-81. https://doi.org/10.1503/cmaj.060911
- Deng SQ, Peng HJ. Characteristics of and Public Health Responses to the Coronavirus Disease 2019 Outbreak in China. J Clin Med 2020;9(2). https://doi.org/10.3390/jcm9020575
- Basille D, Plouvier N, Trouve C, Duhaut P, Andrejak C, Jounieaux V. Non-steroidal Anti-inflammatory Drugs may Worsen the Course of Community-Acquired Pneumonia: A Cohort Study. Lung 2017;195(2):201-208. https://doi.org/10.1007/s00408-016-9973-1
- Douglas I, Evans S, Smeeth L. Effect of statin treatment on short term mortality after pneumonia episode: cohort study. BMJ 2011;342:d1642. https://doi.org/10.1136/bmj.d1642
- Fleming DM, Verlander NQ, Elliot AJ, Zhao H, Gelb D, Jehring D, Nguyen-Van-Tam JS. An assessment of the effect of statin use on the incidence of acute respiratory infections in England during winters 1998-1999 to 2005-2006. Epidemiol Infect 2010;138(9):1281-8. https://doi.org/10.1017/S0950268810000105
- Xu L, Liu J, Lu M, Yang D, Zheng X. Liver injury during highly pathogenic human coronavirus infections. Liver Int 2020;40(5):998-1004. https://doi.org/10.1111/liv.14435
- Knuuti J, Wijns W, Saraste A, Capodanno D, Barbato E, Funck-Brentano C, Prescott E, Storey RF, Deaton C, Cuisset T, Agewall S, Dickstein K, Edvardsen T, Escaned J, Gersh BJ, Svitil P, Gilard M, Hasdai D, Hatala R, Mahfoud F, Masip J, Muneretto C, Valgimigli M, Achenbach S, Bax JJ, Group ESCSD. 2019 ESC Guidelines for the diagnosis and management of chronic coronary syndromes. Eur Heart J 2020;41(3):407-477. https://doi.org/10.1093/eurheartj/ehz425
- Maron DJ, Hochman JS, Reynolds HR, Bangalore S, O'Brien SM, Boden WE, Chaitman BR, Senior R, Lopez-Sendon J, Alexander KP, Lopes RD, Shaw LJ, Berger JS, Newman JD, Sidhu MS, Goodman SG, Ruzyllo W, Gosselin G, Maggioni AP, White HD, Bhargava B, Min JK, Mancini GBJ, Berman DS, Picard MH, Kwong RY, Ali ZA, Mark DB, Spertus JA, Krishnan MN, Elghamaz A, Moorthy N, Hueb WA, Demkow M, Mavromatis K, Bockeria O, Peteiro J, Miller TD, Szwed H, Doerr R, Keltai M, Selvanayagam JB, Steg PG, Held C, Kohsaka S, Mavromichalis S, Kirby R, Jeffries NO, Harrell FE, Jr., Rockhold FW, Broderick S, Ferguson TB, Jr., Williams DO, Harrington RA, Stone GW, Rosenberg Y, Group IR. Initial Invasive or Conservative Strategy for Stable Coronary Disease. N Engl J Med 2020;382(15):1395-1407. https://doi.org/10.1056/NEJMoa1915922
- Li B, Yang J, Zhao F, Zhi L, Wang X, Liu L, Bi Z, Zhao Y. Prevalence and impact of cardiovascular metabolic diseases on COVID-19 in China. Clin Res Cardiol 2020;109(5):531-538. https://doi.org/10.1007/s00392-020-01626-9
- Lippi G, Lavie CJ, Sanchis-Gomar F. Cardiac troponin I in patients with coronavirus disease 2019 (COVID-19): Evidence from a meta-analysis. Prog Cardiovasc Dis 2020. https://doi.org/10.1016/j.pcad.2020.03.001
- Yang W, Cao Q, Qin L, Wang X, Cheng Z, Pan A, Dai J, Sun Q, Zhao F, Qu J, Yan F. Clinical characteristics and imaging manifestations of the 2019 novel coronavirus disease (COVID-19):A multi-center study in Wenzhou city, Zhejiang, China. J Infect 2020;80(4):388-393. https://doi.org/10.1016/j.jinf.2020.02.016
- Celutkiene J, Lainscak M, Anderson L, Gayat E, Grapsa J, Harjola VP, Manka R, Nihoyannopoulos P, Filardi PP, Vrettou R, Anker SD, Filippatos G, Mebazaa A, Metra M, Piepoli M, Ruschitzka F, Zamorano JL, Rosano G, Seferovic P. Imaging in patients with suspected acute heart failure: timeline approach position statement on behalf of the Heart Failure Association of the European Society of Cardiology. Eur J Heart Fail 2020;22(2):181-195. https://doi.org/10.1002/ejhf.1678
- Furuhashi M, Moniwa N, Mita T, Fuseya T, Ishimura S, Ohno K, Shibata S, Tanaka M, Watanabe Y, Akasaka H, Ohnishi H, Yoshida H, Takizawa H, Saitoh S, Ura N, Shimamoto K, Miura T. Urinary angiotensin-converting enzyme 2 in hypertensive patients may be increased by olmesartan, an angiotensin II receptor blocker. Am J Hypertens 2015;28(1):15-21. https://doi.org/10.1093/ajh/hpu086
- Halliday BP, Wassall R, Lota AS, Khalique Z, Gregson J, Newsome S, Jackson R, Rahneva T, Wage R, Smith G, Venneri L, Tayal U, Auger D, Midwinter W, Whiffin N, Rajani R, Dungu JN, Pantazis A, Cook SA, Ware JS, Baksi AJ, Pennell DJ, Rosen SD, Cowie MR, Cleland JGF, Prasad SK. Withdrawal of pharmacological treatment for heart failure in patients with recovered dilated cardiomyopathy (TRED-HF): an open-label, pilot, randomised trial. Lancet 2019;393(10166):61-73. https://doi.org/10.1016/S0140-6736(18)32484-X
- Seferovic PM, Ponikowski P, Anker SD, Bauersachs J, Chioncel O, Cleland JGF, de Boer RA, Drexel H, Ben Gal T, Hill L, Jaarsma T, Jankowska EA, Anker MS, Lainscak M, Lewis BS, McDonagh T, Metra M, Milicic D, Mullens W, Piepoli MF, Rosano G, Ruschitzka F, Volterrani M, Voors AA, Filippatos G, Coats AJS. Clinical practice update on heart failure 2019: pharmacotherapy, procedures, devices and patient management. An expert consensus meeting report of the Heart Failure Association of the European Society of Cardiology. Eur J Heart Fail 2019;21(10):1169-1186. https://doi.org/10.1002/ejhf.1531
- AlGhamdi M, Mushtaq F, Awn N, Shalhoub S. MERS CoV infection in two renal transplant recipients: case report. Am J Transplant 2015;15(4):1101-4. https://doi.org/10.1111/ajt.13085
- Kumar D, Tellier R, Draker R, Levy G, Humar A. Severe Acute Respiratory Syndrome (SARS) in a liver transplant recipient and guidelines for donor SARS screening. Am J Transplant 2003;3(8):977-81. https://doi.org/10.1034/j.1600-6143.2003.00197.x
- Li F, Cai J, Dong N. First cases of COVID-19 in heart transplantation from China. J Heart Lung Transplant 2020;39(5):496-497. https://doi.org/10.1016/j.healun.2020.03.006
- Ren ZL, Hu R, Wang ZW, Zhang M, Ruan YL, Wu ZY, Wu HB, Hu XP, Hu ZP, Ren W, Li LC, Dai FF, Liu H, Cai X. Epidemiologic and clinical characteristics of heart transplant recipients during the 2019 coronavirus outbreak in Wuhan, China: A descriptive survey report. J Heart Lung Transplant 2020;39(5):412-417. https://doi.org/10.1016/j.healun.2020.03.008
- Mehta P, McAuley DF, Brown M, Sanchez E, Tattersall RS, Manson JJ, Hlh Across Speciality Collaboration UK. COVID-19: consider cytokine storm syndromes and immunosuppression. Lancet 2020;395(10229):1033-1034. https://doi.org/10.1016/S0140-6736(20)30628-0
- Rosenhek R, Binder T, Porenta G, Lang I, Christ G, Schemper M, Maurer G, Baumgartner H. Predictors of outcome in severe, asymptomatic aortic stenosis. N Engl J Med 2000;343(9):611-7. https://doi.org/10.1056/NEJM200008313430903
- Rosenhek R, Zilberszac R, Schemper M, Czerny M, Mundigler G, Graf S, Bergler-Klein J, Grimm M, Gabriel H, Maurer G. Natural history of very severe aortic stenosis. Circulation 2010;121(1):151-6. https://doi.org/10.1161/CIRCULATIONAHA.109.894170
- Zlotnick DM, Ouellette ML, Malenka DJ, DeSimone JP, Leavitt BJ, Helm RE, Olmstead EM, Costa SP, DiScipio AW, Likosky DS, Schmoker JD, Quinn RD, Sisto D, Klemperer JD, Sardella GL, Baribeau YR, Frumiento C, Brown JR, O'Rourke DJ, Northern New England Cardiovascular Disease Study G. Effect of preoperative pulmonary hypertension on outcomes in patients with severe aortic stenosis following surgical aortic valve replacement. Am J Cardiol 2013;112(10):1635-40. https://doi.org/10.1016/j.amjcard.2013.07.025
- Bergler-Klein J, Klaar U, Heger M, Rosenhek R, Mundigler G, Gabriel H, Binder T, Pacher R, Maurer G, Baumgartner H. Natriuretic peptides predict symptom-free survival and postoperative outcome in severe aortic stenosis. Circulation 2004;109(19):2302-8. https://doi.org/10.1161/01.CIR.0000126825.50903.18
- Chin CW, Shah AS, McAllister DA, Joanna Cowell S, Alam S, Langrish JP, Strachan FE, Hunter AL, Maria Choy A, Lang CC, Walker S, Boon NA, Newby DE, Mills NL, Dweck MR. High-sensitivity troponin I concentrations are a marker of an advanced hypertrophic response and adverse outcomes in patients with aortic stenosis. Eur Heart J 2014;35(34):2312-21. https://doi.org/10.1093/eurheartj/ehu189
- Clavel MA, Malouf J, Michelena HI, Suri RM, Jaffe AS, Mahoney DW, Enriquez-Sarano M. B-type natriuretic peptide clinical activation in aortic stenosis: impact on long-term survival. J Am Coll Cardiol 2014;63(19):2016-25. https://doi.org/10.1016/j.jacc.2014.02.581
- Otto CM, Prendergast B. Aortic-valve stenosis--from patients at risk to severe valve obstruction. N Engl J Med 2014;371(8):744-56. https://doi.org/10.1056/NEJMra1313875
- Yang J, Zheng Y, Gou X, Pu K, Chen Z, Guo Q, Ji R, Wang H, Wang Y, Zhou Y. Prevalence of comorbidities and its effects in patients infected with SARS-CoV-2: a systematic review and meta-analysis. Int J Infect Dis 2020;94:91-95. https://doi.org/10.1016/j.ijid.2020.03.017
- Leon MB, Smith CR, Mack MJ, Makkar RR, Svensson LG, Kodali SK, Thourani VH, Tuzcu EM, Miller DC, Herrmann HC, Doshi D, Cohen DJ, Pichard AD, Kapadia S, Dewey T, Babaliaros V, Szeto WY, Williams MR, Kereiakes D, Zajarias A, Greason KL, Whisenant BK, Hodson RW, Moses JW, Trento A, Brown DL, Fearon WF, Pibarot P, Hahn RT, Jaber WA, Anderson WN, Alu MC, Webb JG, Investigators P. Transcatheter or Surgical Aortic-Valve Replacement in Intermediate-Risk Patients. N Engl J Med 2016;374(17):1609-20. https://doi.org/10.1056/NEJMoa1514616
- Makkar RR, Thourani VH, Mack MJ, Kodali SK, Kapadia S, Webb JG, Yoon SH, Trento A, Svensson LG, Herrmann HC, Szeto WY, Miller DC, Satler L, Cohen DJ, Dewey TM, Babaliaros V, Williams MR, Kereiakes DJ, Zajarias A, Greason KL, Whisenant BK, Hodson RW, Brown DL, Fearon WF, Russo MJ, Pibarot P, Hahn RT, Jaber WA, Rogers E, Xu K, Wheeler J, Alu MC, Smith CR, Leon MB, Investigators P. Five-Year Outcomes of Transcatheter or Surgical Aortic-Valve Replacement. N Engl J Med 2020;382(9):799-809. https://doi.org/10.1056/NEJMoa1910555
- Mack MJ, Leon MB, Thourani VH, Makkar R, Kodali SK, Russo M, Kapadia SR, Malaisrie SC, Cohen DJ, Pibarot P, Leipsic J, Hahn RT, Blanke P, Williams MR, McCabe JM, Brown DL, Babaliaros V, Goldman S, Szeto WY, Genereux P, Pershad A, Pocock SJ, Alu MC, Webb JG, Smith CR, Investigators P. Transcatheter Aortic-Valve Replacement with a Balloon-Expandable Valve in Low-Risk Patients. N Engl J Med 2019;380(18):1695-1705. https://doi.org/10.1056/NEJMoa1814052
- Popma JJ, Deeb GM, Yakubov SJ, Mumtaz M, Gada H, O'Hair D, Bajwa T, Heiser JC, Merhi W, Kleiman NS, Askew J, Sorajja P, Rovin J, Chetcuti SJ, Adams DH, Teirstein PS, Zorn GL, 3rd, Forrest JK, Tchetche D, Resar J, Walton A, Piazza N, Ramlawi B, Robinson N, Petrossian G, Gleason TG, Oh JK, Boulware MJ, Qiao H, Mugglin AS, Reardon MJ, Evolut Low Risk Trial I. Transcatheter Aortic-Valve Replacement with a Self-Expanding Valve in Low-Risk Patients. N Engl J Med 2019;380(18):1706-1715. https://doi.org/10.1056/NEJMoa1816885
- Arora S, Strassle PD, Kolte D, Ramm CJ, Falk K, Jack G, Caranasos TG, Cavender MA, Rossi JS, Vavalle JP. Length of Stay and Discharge Disposition After Transcatheter Versus Surgical Aortic Valve Replacement in the United States. Circ Cardiovasc Interv 2018;11(9):e006929. https://doi.org/10.1161/CIRCINTERVENTIONS.118.006929
- Ponikowski P, Voors AA, Anker SD, Bueno H, Cleland JGF, Coats AJS, Falk V, Gonzalez-Juanatey JR, Harjola VP, Jankowska EA, Jessup M, Linde C, Nihoyannopoulos P, Parissis JT, Pieske B, Riley JP, Rosano GMC, Ruilope LM, Ruschitzka F, Rutten FH, van der Meer P, Group ESCSD. 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: The Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC)Developed with the special contribution of the Heart Failure Association (HFA) of the ESC. Eur Heart J 2016;37(27):2129-2200. https://doi.org/10.1093/eurheartj/ehw128
- Asgar AW, Mack MJ, Stone GW. Secondary mitral regurgitation in heart failure: pathophysiology, prognosis, and therapeutic considerations. J Am Coll Cardiol 2015;65(12):1231-1248. https://doi.org/10.1016/j.jacc.2015.02.009
- Kang DH, Park SJ, Shin SH, Hong GR, Lee S, Kim MS, Yun SC, Song JM, Park SW, Kim JJ. Angiotensin Receptor Neprilysin Inhibitor for Functional Mitral Regurgitation. Circulation 2019;139(11):1354-1365. https://doi.org/10.1161/CIRCULATIONAHA.118.037077
- Zilberszac R, Heinze G, Binder T, Laufer G, Gabriel H, Rosenhek R. Long-Term Outcome of Active Surveillance in Severe But Asymptomatic Primary Mitral Regurgitation. JACC Cardiovasc Imaging 2018;11(9):1213-1221. https://doi.org/10.1016/j.jcmg.2018.05.014
- Sorajja P, Vemulapalli S, Feldman T, Mack M, Holmes DR, Jr., Stebbins A, Kar S, Thourani V, Ailawadi G. Outcomes With Transcatheter Mitral Valve Repair in the United States: An STS/ACC TVT Registry Report. J Am Coll Cardiol 2017;70(19):2315-2327. https://doi.org/10.1016/j.jacc.2017.09.015
- Zhang JJ, Dong X, Cao YY, Yuan YD, Yang YB, Yan YQ, Akdis CA, Gao YD. Clinical characteristics of 140 patients infected with SARS-CoV-2 in Wuhan, China. Allergy 2020. https://doi.org/10.1111/all.14238
- Williams B, Mancia G, Spiering W, Agabiti Rosei E, Azizi M, Burnier M, Clement DL, Coca A, de Simone G, Dominiczak A, Kahan T, Mahfoud F, Redon J, Ruilope L, Zanchetti A, Kerins M, Kjeldsen SE, Kreutz R, Laurent S, Lip GYH, McManus R, Narkiewicz K, Ruschitzka F, Schmieder RE, Shlyakhto E, Tsioufis C, Aboyans V, Desormais I, Group ESCSD. 2018 ESC/ESH Guidelines for the management of arterial hypertension. Eur Heart J 2018;39(33):3021-3104. https://doi.org/10.1093/eurheartj/ehy339
- Sommerstein R, Grani C. Rapid Response: Re: Preventing a covid-19 pandemic: ACE inhibitors as a potential risk factor for fatal Covid-19. BMJ 2020;368:m810. https://doi.org/10.1136/bmj.m810
- Chen Y, Guo Y, Pan Y, Zhao ZJ. Structure analysis of the receptor binding of 2019-nCoV. Biochem Biophys Res Commun 2020. https://doi.org/10.1016/j.bbrc.2020.02.071
- Burrell LM, Risvanis J, Kubota E, Dean RG, MacDonald PS, Lu S, Tikellis C, Grant SL, Lew RA, Smith AI, Cooper ME, Johnston CI. Myocardial infarction increases ACE2 expression in rat and humans. Eur Heart J 2005;26(4):369-75; discussion 322-4. https://doi.org/10.1093/eurheartj/ehi114
- Ishiyama Y, Gallagher PE, Averill DB, Tallant EA, Brosnihan KB, Ferrario CM. Upregulation of angiotensin-converting enzyme 2 after myocardial infarction by blockade of angiotensin II receptors. Hypertension 2004;43(5):970-6. https://doi.org/10.1161/01.HYP.0000124667.34652.1a
- Imai Y, Kuba K, Rao S, Huan Y, Guo F, Guan B, Yang P, Sarao R, Wada T, Leong-Poi H, Crackower MA, Fukamizu A, Hui CC, Hein L, Uhlig S, Slutsky AS, Jiang C, Penninger JM. Angiotensin-converting enzyme 2 protects from severe acute lung failure. Nature 2005;436(7047):112-6. https://doi.org/10.1038/nature03712
- Kuba K, Imai Y, Rao S, Gao H, Guo F, Guan B, Huan Y, Yang P, Zhang Y, Deng W, Bao L, Zhang B, Liu G, Wang Z, Chappell M, Liu Y, Zheng D, Leibbrandt A, Wada T, Slutsky AS, Liu D, Qin C, Jiang C, Penninger JM. A crucial role of angiotensin converting enzyme 2 (ACE2) in SARS coronavirus-induced lung injury. Nat Med 2005;11(8):875-9. https://doi.org/10.1038/nm1267
- Rodrigues Prestes TR, Rocha NP, Miranda AS, Teixeira AL, Simoes ESAC. The Anti-Inflammatory Potential of ACE2/Angiotensin-(1-7)/Mas Receptor Axis: Evidence from Basic and Clinical Research. Curr Drug Targets 2017;18(11):1301-1313. https://doi.org/10.2174/1389450117666160727142401
- ClinicalTrials.gov [Internet]. Bethesda (MD): National Library of Medicine (US). Identifier NCT04287686, Recombinant Human Angiotensin-converting Enzyme 2 (rhACE2) as a Treatment for Patients With COVID-19. https://clinicaltrials.gov/ct2/show/NCT04287686 (March 17, 2020; date last accessed).
- Gurwitz D. Angiotensin receptor blockers as tentative SARS-CoV-2 therapeutics. Drug Dev Res 2020. https://doi.org/10.1002/ddr.21656
- de Simone G, ESC Council on Hypertension, On behalf of the Nucleus Members. Position Statement of the ESC Council on Hypertension on ACE-Inhibitors and Angiotensin Receptor Blockers. https://www.escardio.org/Councils/Council-on-Hypertension-(CHT)/News/position-statement-of-the-esc-council-on-hypertension-on-ace-inhibitors-and-ang (March 13, 2020; date last accessed).
- Lip GYH, Coca A, Kahan T, Boriani G, Manolis AS, Olsen MH, Oto A, Potpara TS, Steffel J, Marin F, de Oliveira Figueiredo MJ, de Simone G, Tzou WS, Chiang CE, Williams B, Reviewers, Dan GA, Gorenek B, Fauchier L, Savelieva I, Hatala R, van Gelder I, Brguljan-Hitij J, Erdine S, Lovic D, Kim YH, Salinas-Arce J, Field M. Hypertension and cardiac arrhythmias: a consensus document from the European Heart Rhythm Association (EHRA) and ESC Council on Hypertension, endorsed by the Heart Rhythm Society (HRS), Asia-Pacific Heart Rhythm Society (APHRS) and Sociedad Latinoamericana de Estimulacion Cardiaca y Electrofisiologia (SOLEACE). Europace 2017;19(6):891-911. https://doi.org/10.1093/europace/eux091
- Tsang OT, Chau TN, Choi KW, Tso EY, Lim W, Chiu MC, Tong WL, Lee PO, Lam BH, Ng TK, Lai JY, Yu WC, Lai ST. Coronavirus-positive nasopharyngeal aspirate as predictor for severe acute respiratory syndrome mortality. Emerg Infect Dis 2003;9(11):1381-7. https://doi.org/10.3201/eid0911.030400
- chen d, Li X, song q, Hu C, Su F, Dai J. Hypokalemia and Clinical Implications in Patients with Coronavirus Disease 2019 (COVID-19). medRxiv 2020:2020.02.27.20028530. https://doi.org/10.1101/2020.02.27.20028530
- Chen J, Wang X, Zhang S, Liu B, Wu X, Wang Y, Wang X, Yang M, Sun J, Xie Y. Findings of Acute Pulmonary Embolism in COVID-19 Patients. SSRN Electronic Journal 2020;Preprints. https://doi.org/10.2139/ssrn.3548771
- Danzi GB, Loffi M, Galeazzi G, Gherbesi E. Acute pulmonary embolism and COVID-19 pneumonia: a random association? Eur Heart J 2020;41(19):1858. https://doi.org/10.1093/eurheartj/ehaa254
- Xie Y, Wang X, Yang P, Zhang S. COVID-19 Complicated by Acute Pulmonary Embolism. Radiology: Cardiothoracic Imaging 2020;2(2):e200067. https://doi.org/10.1148/ryct.2020200067
- Huisman MV, Barco S, Cannegieter SC, Le Gal G, Konstantinides SV, Reitsma PH, Rodger M, Vonk Noordegraaf A, Klok FA. Pulmonary embolism. Nat Rev Dis Primers 2018;4:18028. https://doi.org/10.1038/nrdp.2018.28
- Cardiac Society of Australia and New Zealand. COVID-19 resources. https://www.csanz.edu.au/resources/ (April 1, 2020; date last accessed).
- Hearth Rythm Society. HRS COVID-19 Task Force Message. https://www.hrsonline.org/COVID19-Challenges-Solutions/Message (March 20, 2020; date last accessed).
- National Health Society. NHS Clinical guide for the management of cardiology patients during the coronavirus pandemic. https://www.england.nhs.uk/coronavirus/publication/specialty-guides/ (April 1, 2020; date last accessed).
- Boriani G, Fauchier L, Aguinaga L, Beattie JM, Blomstrom Lundqvist C, Cohen A, Dan GA, Genovesi S, Israel C, Joung B, Kalarus Z, Lampert R, Malavasi VL, Mansourati J, Mont L, Potpara T, Thornton A, Lip GYH, Group ESCSD. European Heart Rhythm Association (EHRA) consensus document on management of arrhythmias and cardiac electronic devices in the critically ill and post-surgery patient, endorsed by Heart Rhythm Society (HRS), Asia Pacific Heart Rhythm Society (APHRS), Cardiac Arrhythmia Society of Southern Africa (CASSA), and Latin American Heart Rhythm Society (LAHRS). Europace 2019;21(1):7-8. https://doi.org/10.1093/europace/euy110
- Brugada J, Katritsis DG, Arbelo E, Arribas F, Bax JJ, Blomstrom-Lundqvist C, Calkins H, Corrado D, Deftereos SG, Diller GP, Gomez-Doblas JJ, Gorenek B, Grace A, Ho SY, Kaski JC, Kuck KH, Lambiase PD, Sacher F, Sarquella-Brugada G, Suwalski P, Zaza A, Group ESCSD. 2019 ESC Guidelines for the management of patients with supraventricular tachycardiaThe Task Force for the management of patients with supraventricular tachycardia of the European Society of Cardiology (ESC). Eur Heart J 2020;41(5):655-720. https://doi.org/10.1093/eurheartj/ehz467
- European Society of Cardiology, European Heart Rhythm Association, Brignole M, Auricchio A, Baron-Esquivias G, Bordachar P, Boriani G, Breithardt OA, Cleland J, Deharo JC, Delgado V, Elliott PM, Gorenek B, Israel CW, Leclercq C, Linde C, Mont L, Padeletti L, Sutton R, Vardas PE. 2013 ESC guidelines on cardiac pacing and cardiac resynchronization therapy: the task force on cardiac pacing and resynchronization therapy of the European Society of Cardiology (ESC). Developed in collaboration with the European Heart Rhythm Association (EHRA). Europace 2013;15(8):1070-118. https://doi.org/10.1093/europace/eut206
- Kirchhof P, Benussi S, Kotecha D, Ahlsson A, Atar D, Casadei B, Castella M, Diener HC, Heidbuchel H, Hendriks J, Hindricks G, Manolis AS, Oldgren J, Popescu BA, Schotten U, Van Putte B, Vardas P, Agewall S, Camm J, Baron Esquivias G, Budts W, Carerj S, Casselman F, Coca A, De Caterina R, Deftereos S, Dobrev D, Ferro JM, Filippatos G, Fitzsimons D, Gorenek B, Guenoun M, Hohnloser SH, Kolh P, Lip GY, Manolis A, McMurray J, Ponikowski P, Rosenhek R, Ruschitzka F, Savelieva I, Sharma S, Suwalski P, Tamargo JL, Taylor CJ, Van Gelder IC, Voors AA, Windecker S, Zamorano JL, Zeppenfeld K. 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Europace 2016;18(11):1609-1678. https://doi.org/10.1093/europace/euw295
- Monsieurs KG, Nolan JP, Bossaert LL, Greif R, Maconochie IK, Nikolaou NI, Perkins GD, Soar J, Truhlar A, Wyllie J, Zideman DA, Group ERCGW. European Resuscitation Council Guidelines for Resuscitation 2015: Section 1. Executive summary. Resuscitation 2015;95:1-80. https://doi.org/10.1016/j.resuscitation.2015.07.038
- Priori SG, Blomstrom-Lundqvist C, Mazzanti A, Blom N, Borggrefe M, Camm J, Elliott PM, Fitzsimons D, Hatala R, Hindricks G, Kirchhof P, Kjeldsen K, Kuck KH, Hernandez-Madrid A, Nikolaou N, Norekval TM, Spaulding C, Van Veldhuisen DJ, Group ESCSD. 2015 ESC Guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death: The Task Force for the Management of Patients with Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death of the European Society of Cardiology (ESC). Endorsed by: Association for European Paediatric and Congenital Cardiology (AEPC). Eur Heart J 2015;36(41):2793-2867. https://doi.org/10.1093/eurheartj/ehv316
- Priori SG, Wilde AA, Horie M, Cho Y, Behr ER, Berul C, Blom N, Brugada J, Chiang CE, Huikuri H, Kannankeril P, Krahn A, Leenhardt A, Moss A, Schwartz PJ, Shimizu W, Tomaselli G, Tracy C, Document R, Ackerman M, Belhassen B, Estes NA, 3rd, Fatkin D, Kalman J, Kaufman E, Kirchhof P, Schulze-Bahr E, Wolpert C, Vohra J, Refaat M, Etheridge SP, Campbell RM, Martin ET, Quek SC, Heart Rhythm S, European Heart Rhythm A, Asia Pacific Heart Rhythm S. Executive summary: HRS/EHRA/APHRS expert consensus statement on the diagnosis and management of patients with inherited primary arrhythmia syndromes. Europace 2013;15(10):1389-406. https://doi.org/10.1093/europace/eut272
- Ambrus DB, Benjamin EJ, Bajwa EK, Hibbert KA, Walkey AJ. Risk factors and outcomes associated with new-onset atrial fibrillation during acute respiratory distress syndrome. J Crit Care 2015;30(5):994-7. https://doi.org/10.1016/j.jcrc.2015.06.003
- Klein Klouwenberg PM, Frencken JF, Kuipers S, Ong DS, Peelen LM, van Vught LA, Schultz MJ, van der Poll T, Bonten MJ, Cremer OL, * MC. Incidence, Predictors, and Outcomes of New-Onset Atrial Fibrillation in Critically Ill Patients with Sepsis. A Cohort Study. Am J Respir Crit Care Med 2017;195(2):205-211. https://doi.org/10.1164/rccm.201603-0618OC
- Walkey AJ, Hammill BG, Curtis LH, Benjamin EJ. Long-term outcomes following development of new-onset atrial fibrillation during sepsis. Chest 2014;146(5):1187-1195. https://doi.org/10.1378/chest.14-0003
- Madjid M, Connolly AT, Nabutovsky Y, Safavi-Naeini P, Razavi M, Miller CC. Effect of High Influenza Activity on Risk of Ventricular Arrhythmias Requiring Therapy in Patients With Implantable Cardiac Defibrillators and Cardiac Resynchronization Therapy Defibrillators. Am J Cardiol 2019;124(1):44-50. https://doi.org/10.1016/j.amjcard.2019.04.011
- Wu CI, Postema PG, Arbelo E, Behr ER, Bezzina CR, Napolitano C, Robyns T, Probst V, Schulze-Bahr E, Remme CA, Wilde AAM. SARS-CoV-2, COVID-19, and inherited arrhythmia syndromes. Heart Rhythm 2020. https://doi.org/10.1016/j.hrthm.2020.03.024
- Chang D, Saleh M, Garcia-Bengo Y, Choi E, Epstein L, Willner J. COVID-19 Infection Unmasking Brugada Syndrome. HeartRhythm Case Rep 2020. https://doi.org/10.1016/j.hrcr.2020.03.012
- Azarkish M, Laleh Far V, Eslami M, Mollazadeh R. Transient complete heart block in a patient with critical COVID-19. Eur Heart J 2020. https://doi.org/10.1093/eurheartj/ehaa307
- Alexander LK, Keene BW, Yount BL, Geratz JD, Small JD, Baric RS. ECG changes after rabbit coronavirus infection. J Electrocardiol 1999;32(1):21-32. https://doi.org/10.1016/s0022-0736(99)90018-3
- Colson P, Rolain JM, Lagier JC, Brouqui P, Raoult D. Chloroquine and hydroxychloroquine as available weapons to fight COVID-19. Int J Antimicrob Agents 2020;55(4):105932. https://doi.org/10.1016/j.ijantimicag.2020.105932
- Gautret P, Lagier JC, Parola P, Hoang VT, Meddeb L, Mailhe M, Doudier B, Courjon J, Giordanengo V, Vieira VE, Dupont HT, Honore S, Colson P, Chabriere E, La Scola B, Rolain JM, Brouqui P, Raoult D. Hydroxychloroquine and azithromycin as a treatment of COVID-19: results of an open-label non-randomized clinical trial. Int J Antimicrob Agents 2020:105949. https://doi.org/10.1016/j.ijantimicag.2020.105949
- Wang M, Cao R, Zhang L, Yang X, Liu J, Xu M, Shi Z, Hu Z, Zhong W, Xiao G. Remdesivir and chloroquine effectively inhibit the recently emerged novel coronavirus (2019-nCoV) in vitro. Cell Res 2020;30(3):269-271. https://doi.org/10.1038/s41422-020-0282-0
- Yao X, Ye F, Zhang M, Cui C, Huang B, Niu P, Liu X, Zhao L, Dong E, Song C, Zhan S, Lu R, Li H, Tan W, Liu D. In Vitro Antiviral Activity and Projection of Optimized Dosing Design of Hydroxychloroquine for the Treatment of Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2). Clin Infect Dis 2020. https://doi.org/10.1093/cid/ciaa237
- Smith T, Bushek J, Prosser T. COVID-19 Drug Therapy – Potential Options. https://www.elsevier.com/connect/coronavirus-information-center (March 26, 2020; date last accessed).
- Haeusler IL, Chan XHS, Guerin PJ, White NJ. The arrhythmogenic cardiotoxicity of the quinoline and structurally related antimalarial drugs: a systematic review. BMC Med 2018;16(1):200. https://doi.org/10.1186/s12916-018-1188-2
- Arabi YM, Asiri AY, Assiri AM, Aziz Jokhdar HA, Alothman A, Balkhy HH, AlJohani S, Al Harbi S, Kojan S, Al Jeraisy M, Deeb AM, Memish ZA, Ghazal S, Al Faraj S, Al-Hameed F, AlSaedi A, Mandourah Y, Al Mekhlafi GA, Sherbeeni NM, Elzein FE, Almotairi A, Al Bshabshe A, Kharaba A, Jose J, Al Harthy A, Al Sulaiman M, Mady A, Fowler RA, Hayden FG, Al-Dawood A, Abdelzaher M, Bajhmom W, Hussein MA, and the Saudi Critical Care Trials g. Treatment of Middle East respiratory syndrome with a combination of lopinavir/ritonavir and interferon-beta1b (MIRACLE trial): statistical analysis plan for a recursive two-stage group sequential randomized controlled trial. Trials 2020;21(1):8. https://doi.org/10.1186/s13063-019-3846-x
- Chan JF, Yao Y, Yeung ML, Deng W, Bao L, Jia L, Li F, Xiao C, Gao H, Yu P, Cai JP, Chu H, Zhou J, Chen H, Qin C, Yuen KY. Treatment With Lopinavir/Ritonavir or Interferon-beta1b Improves Outcome of MERS-CoV Infection in a Nonhuman Primate Model of Common Marmoset. J Infect Dis 2015;212(12):1904-13. https://doi.org/10.1093/infdis/jiv392
- de Wilde AH, Jochmans D, Posthuma CC, Zevenhoven-Dobbe JC, van Nieuwkoop S, Bestebroer TM, van den Hoogen BG, Neyts J, Snijder EJ. Screening of an FDA-approved compound library identifies four small-molecule inhibitors of Middle East respiratory syndrome coronavirus replication in cell culture. Antimicrob Agents Chemother 2014;58(8):4875-84. https://doi.org/10.1128/AAC.03011-14
- Park SY, Lee JS, Son JS, Ko JH, Peck KR, Jung Y, Woo HJ, Joo YS, Eom JS, Shi H. Post-exposure prophylaxis for Middle East respiratory syndrome in healthcare workers. J Hosp Infect 2019;101(1):42-46. https://doi.org/10.1016/j.jhin.2018.09.005
- Cao B, Wang Y, Wen D, Liu W, Wang J, Fan G, Ruan L, Song B, Cai Y, Wei M, Li X, Xia J, Chen N, Xiang J, Yu T, Bai T, Xie X, Zhang L, Li C, Yuan Y, Chen H, Li H, Huang H, Tu S, Gong F, Liu Y, Wei Y, Dong C, Zhou F, Gu X, Xu J, Liu Z, Zhang Y, Li H, Shang L, Wang K, Li K, Zhou X, Dong X, Qu Z, Lu S, Hu X, Ruan S, Luo S, Wu J, Peng L, Cheng F, Pan L, Zou J, Jia C, Wang J, Liu X, Wang S, Wu X, Ge Q, He J, Zhan H, Qiu F, Guo L, Huang C, Jaki T, Hayden FG, Horby PW, Zhang D, Wang C. A Trial of Lopinavir-Ritonavir in Adults Hospitalized with Severe Covid-19. N Engl J Med 2020;382(19):1787-1799. https://doi.org/10.1056/NEJMoa2001282
- de Wit E, Feldmann F, Cronin J, Jordan R, Okumura A, Thomas T, Scott D, Cihlar T, Feldmann H. Prophylactic and therapeutic remdesivir (GS-5734) treatment in the rhesus macaque model of MERS-CoV infection. Proc Natl Acad Sci U S A 2020;117(12):6771-6776. https://doi.org/10.1073/pnas.1922083117
- Sheahan TP, Sims AC, Graham RL, Menachery VD, Gralinski LE, Case JB, Leist SR, Pyrc K, Feng JY, Trantcheva I, Bannister R, Park Y, Babusis D, Clarke MO, Mackman RL, Spahn JE, Palmiotti CA, Siegel D, Ray AS, Cihlar T, Jordan R, Denison MR, Baric RS. Broad-spectrum antiviral GS-5734 inhibits both epidemic and zoonotic coronaviruses. Sci Transl Med 2017;9(396). https://doi.org/10.1126/scitranslmed.aal3653
- Sheahan TP, Sims AC, Leist SR, Schafer A, Won J, Brown AJ, Montgomery SA, Hogg A, Babusis D, Clarke MO, Spahn JE, Bauer L, Sellers S, Porter D, Feng JY, Cihlar T, Jordan R, Denison MR, Baric RS. Comparative therapeutic efficacy of remdesivir and combination lopinavir, ritonavir, and interferon beta against MERS-CoV. Nat Commun 2020;11(1):222. https://doi.org/10.1038/s41467-019-13940-6
- Howard PA. Azithromycin-induced proarrhythmia and cardiovascular death. Ann Pharmacother 2013;47(11):1547-51. https://doi.org/10.1177/1060028013504905
- Poluzzi E, Raschi E, Motola D, Moretti U, De Ponti F. Antimicrobials and the risk of torsades de pointes: the contribution from data mining of the US FDA Adverse Event Reporting System. Drug Saf 2010;33(4):303-14. https://doi.org/10.2165/11531850-000000000-00000
- Kimani J, Phiri K, Kamiza S, Duparc S, Ayoub A, Rojo R, Robbins J, Orrico R, Vandenbroucke P. Efficacy and Safety of Azithromycin-Chloroquine versus Sulfadoxine-Pyrimethamine for Intermittent Preventive Treatment of Plasmodium falciparum Malaria Infection in Pregnant Women in Africa: An Open-Label, Randomized Trial. PLoS One 2016;11(6):e0157045. https://doi.org/10.1371/journal.pone.0157045
- Sagara I, Oduro AR, Mulenga M, Dieng Y, Ogutu B, Tiono AB, Mugyenyi P, Sie A, Wasunna M, Kain KC, Djimde AA, Sarkar S, Chandra R, Robbins J, Dunne MW. Efficacy and safety of a combination of azithromycin and chloroquine for the treatment of uncomplicated Plasmodium falciparum malaria in two multi-country randomised clinical trials in African adults. Malar J 2014;13:458. https://doi.org/10.1186/1475-2875-13-458
- Vicente J, Zusterzeel R, Johannesen L, Ochoa-Jimenez R, Mason JW, Sanabria C, Kemp S, Sager PT, Patel V, Matta MK, Liu J, Florian J, Garnett C, Stockbridge N, Strauss DG. Assessment of Multi-Ion Channel Block in a Phase I Randomized Study Design: Results of the CiPA Phase I ECG Biomarker Validation Study. Clin Pharmacol Ther 2019;105(4):943-953. https://doi.org/10.1002/cpt.1303
- Mzayek F, Deng H, Mather FJ, Wasilevich EC, Liu H, Hadi CM, Chansolme DH, Murphy HA, Melek BH, Tenaglia AN, Mushatt DM, Dreisbach AW, Lertora JJ, Krogstad DJ. Randomized dose-ranging controlled trial of AQ-13, a candidate antimalarial, and chloroquine in healthy volunteers. PLoS Clin Trials 2007;2(1):e6. https://doi.org/10.1371/journal.pctr.0020006
- Wozniacka A, Cygankiewicz I, Chudzik M, Sysa-Jedrzejowska A, Wranicz JK. The cardiac safety of chloroquine phosphate treatment in patients with systemic lupus erythematosus: the influence on arrhythmia, heart rate variability and repolarization parameters. Lupus 2006;15(8):521-5. https://doi.org/10.1191/0961203306lu2345oa
- Teixeira RA, Martinelli Filho M, Benvenuti LA, Costa R, Pedrosa AA, Nishioka SA. Cardiac damage from chronic use of chloroquine: a case report and review of the literature. Arq Bras Cardiol 2002;79(1):85-8. https://doi.org/10.1590/s0066-782x2002001000009
- Lee JH, Chung WB, Kang JH, Kim HW, Kim JJ, Kim JH, Hwang HJ, Lee JB, Chung JW, Kim HL, Choi YS, Park CS, Youn HJ, Lee MY. A case of chloroquine-induced cardiomyopathy that presented as sick sinus syndrome. Korean Circ J 2010;40(11):604-8. https://doi.org/10.4070/kcj.2010.40.11.604
- McGhie TK, Harvey P, Su J, Anderson N, Tomlinson G, Touma Z. Electrocardiogram abnormalities related to anti-malarials in systemic lupus erythematosus. Clin Exp Rheumatol 2018;36(4):545-551.
- Teixeira RA, Borba EF, Pedrosa A, Nishioka S, Viana VS, Ramires JA, Kalil-Filho R, Bonfa E, Martinelli Filho M. Evidence for cardiac safety and antiarrhythmic potential of chloroquine in systemic lupus erythematosus. Europace 2014;16(6):887-92. https://doi.org/10.1093/europace/eut290
- Yogasundaram H, Putko BN, Tien J, Paterson DI, Cujec B, Ringrose J, Oudit GY. Hydroxychloroquine-induced cardiomyopathy: case report, pathophysiology, diagnosis, and treatment. Can J Cardiol 2014;30(12):1706-15. https://doi.org/10.1016/j.cjca.2014.08.016
- Capel RA, Herring N, Kalla M, Yavari A, Mirams GR, Douglas G, Bub G, Channon K, Paterson DJ, Terrar DA, Burton RA. Hydroxychloroquine reduces heart rate by modulating the hyperpolarization-activated current If: Novel electrophysiological insights and therapeutic potential. Heart Rhythm 2015;12(10):2186-94. https://doi.org/10.1016/j.hrthm.2015.05.027
- Mollerach FB, Scolnik M, Catoggio LJ, Rosa J, Soriano ER. Causes of fetal third-degree atrioventricular block and use of hydroxychloroquine in pregnant women with Ro/La antibodies. Clin Rheumatol 2019;38(8):2211-2217. https://doi.org/10.1007/s10067-019-04556-8
- Zhang M, Xie M, Li S, Gao Y, Xue S, Huang H, Chen K, Liu F, Chen L. Electrophysiologic Studies on the Risks and Potential Mechanism Underlying the Proarrhythmic Nature of Azithromycin. Cardiovasc Toxicol 2017;17(4):434-440. https://doi.org/10.1007/s12012-017-9401-7
- Choi Y, Lim HS, Chung D, Choi JG, Yoon D. Risk Evaluation of Azithromycin-Induced QT Prolongation in Real-World Practice. Biomed Res Int 2018;2018:1574806. https://doi.org/10.1155/2018/1574806
- U.S. Food and Drug Administration. ZITHROMAX (azithromycin) for IV infusion only. Highlights of prescribing information. Reference ID: 4051690 https://www.accessdata.fda.gov/drugsatfda_docs/label/2017/050693s27-050730s35lbl.pdf.
- Ray WA, Murray KT, Hall K, Arbogast PG, Stein CM. Azithromycin and the risk of cardiovascular death. N Engl J Med 2012;366(20):1881-90. https://doi.org/10.1056/NEJMoa1003833
- Cheng YJ, Nie XY, Chen XM, Lin XX, Tang K, Zeng WT, Mei WY, Liu LJ, Long M, Yao FJ, Liu J, Liao XX, Du ZM, Dong YG, Ma H, Xiao HP, Wu SH. The Role of Macrolide Antibiotics in Increasing Cardiovascular Risk. J Am Coll Cardiol 2015;66(20):2173-2184. https://doi.org/10.1016/j.jacc.2015.09.029
- Maisch NM, Kochupurackal JG, Sin J. Azithromycin and the risk of cardiovascular complications. J Pharm Pract 2014;27(5):496-500. https://doi.org/10.1177/0897190013516503
- Lu ZK, Yuan J, Li M, Sutton SS, Rao GA, Jacob S, Bennett CL. Cardiac risks associated with antibiotics: azithromycin and levofloxacin. Expert Opin Drug Saf 2015;14(2):295-303. https://doi.org/10.1517/14740338.2015.989210
- Rao GA, Mann JR, Shoaibi A, Bennett CL, Nahhas G, Sutton SS, Jacob S, Strayer SM. Azithromycin and levofloxacin use and increased risk of cardiac arrhythmia and death. Ann Fam Med 2014;12(2):121-7. https://doi.org/10.1370/afm.1601
- Rathbun CR, Liedtke MD, Blevins SM, Harrison D, Lockhart SM, Salvaggio M, Acosta EP. Electrocardiogram abnormalities with atazanavir and lopinavir/ritonavir. HIV Clin Trials 2009;10(5):328-36. https://doi.org/10.1310/hct1005-328
- Grange S, Schmitt C, Banken L, Kuhn B, Zhang X. Thorough QT/QTc study of tocilizumab after single-dose administration at therapeutic and supratherapeutic doses in healthy subjects. Int J Clin Pharmacol Ther 2011;49(11):648-55. https://doi.org/10.5414/cp201549
- Akbulak RO, Rosenkranz SC, Schaeffer BN, Pinnschmidt HO, Willems S, Heesen C, Hoffmann BA. Acute and long-term effects of fingolimod on heart rhythm and heart rate variability in patients with multiple sclerosis. Mult Scler Relat Disord 2018;19:44-49. https://doi.org/10.1016/j.msard.2017.10.020
- Gold R, Comi G, Palace J, Siever A, Gottschalk R, Bijarnia M, von Rosenstiel P, Tomic D, Kappos L, Investigators FS. Assessment of cardiac safety during fingolimod treatment initiation in a real-world relapsing multiple sclerosis population: a phase 3b, open-label study. J Neurol 2014;261(2):267-76. https://doi.org/10.1007/s00415-013-7115-8
- Limmroth V, Ziemssen T, Lang M, Richter S, Wagner B, Haas J, Schmidt S, Gerbershagen K, Lassek C, Klotz L, Hoffmann O, Albert C, Schuh K, Baier-Ebert M, Wendt G, Schieb H, Hoyer S, Dechend R, Haverkamp W. Electrocardiographic assessments and cardiac events after fingolimod first dose - a comprehensive monitoring study. BMC Neurol 2017;17(1):11. https://doi.org/10.1186/s12883-016-0789-7
- Brown B, Weiss JL, Kolodny S, Meng X, Williams IM, Osborne JA. Analysis of cardiac monitoring and safety data in patients initiating fingolimod treatment in the home or in clinic. BMC Neurol 2019;19(1):287. https://doi.org/10.1186/s12883-019-1506-0
- Jacobs M, Rodger A, Bell DJ, Bhagani S, Cropley I, Filipe A, Gifford RJ, Hopkins S, Hughes J, Jabeen F, Johannessen I, Karageorgopoulos D, Lackenby A, Lester R, Liu RS, MacConnachie A, Mahungu T, Martin D, Marshall N, Mepham S, Orton R, Palmarini M, Patel M, Perry C, Peters SE, Porter D, Ritchie D, Ritchie ND, Seaton RA, Sreenu VB, Templeton K, Warren S, Wilkie GS, Zambon M, Gopal R, Thomson EC. Late Ebola virus relapse causing meningoencephalitis: a case report. Lancet 2016;388(10043):498-503. https://doi.org/10.1016/S0140-6736(16)30386-5
- Sodero A, Squitieri M, Mazzeo S, Pasca M, Mata S, Pieri F, Bessi V, Sorbi S. Acute Symptomatic Sinus Bradycardia in High-Dose Methylprednisolone Therapy in a Woman With Inflammatory Myelitis: A Case Report and Review of the Literature. Clin Med Insights Case Rep 2019;12:1179547619831026. https://doi.org/10.1177/1179547619831026
- Vasheghani-Farahani A, Sahraian MA, Darabi L, Aghsaie A, Minagar A. Incidence of various cardiac arrhythmias and conduction disturbances due to high dose intravenous methylprednisolone in patients with multiple sclerosis. J Neurol Sci 2011;309(1-2):75-8. https://doi.org/10.1016/j.jns.2011.07.018
- Giudicessi JR, Noseworthy PA, Friedman PA, Ackerman MJ. Urgent Guidance for Navigating and Circumventing the QTc-Prolonging and Torsadogenic Potential of Possible Pharmacotherapies for Coronavirus Disease 19 (COVID-19). Mayo Clin Proc 2020;[published online ahead of print March 25, 2020]. https://doi.org/10.1016/j.mayocp.2020.03.024
- Yang T, Roden DM. Extracellular potassium modulation of drug block of IKr. Implications for torsade de pointes and reverse use-dependence. Circulation 1996;93(3):407-11. https://doi.org/10.1161/01.cir.93.3.407
- Garabelli P, Stavrakis S, Albert M, Koomson E, Parwani P, Chohan J, Smith L, Albert D, Xie R, Xie Q, Reynolds D, Po S. Comparison of QT Interval Readings in Normal Sinus Rhythm Between a Smartphone Heart Monitor and a 12-Lead ECG for Healthy Volunteers and Inpatients Receiving Sotalol or Dofetilide. J Cardiovasc Electrophysiol 2016;27(7):827-32. https://doi.org/10.1111/jce.12976
- Steffel J, Verhamme P, Potpara TS, Albaladejo P, Antz M, Desteghe L, Haeusler KG, Oldgren J, Reinecke H, Roldan-Schilling V, Rowell N, Sinnaeve P, Collins R, Camm AJ, Heidbuchel H, Group ESCSD. The 2018 European Heart Rhythm Association Practical Guide on the use of non-vitamin K antagonist oral anticoagulants in patients with atrial fibrillation. Eur Heart J 2018;39(16):1330-1393. https://doi.org/10.1093/eurheartj/ehy136
- Duchin K, Duggal A, Atiee GJ, Kidokoro M, Takatani T, Shipitofsky NL, He L, Zhang G, Kakkar T. An Open-Label Crossover Study of the Pharmacokinetics of the 60-mg Edoxaban Tablet Crushed and Administered Either by a Nasogastric Tube or in Apple Puree in Healthy Adults. Clin Pharmacokinet 2018;57(2):221-228. https://doi.org/10.1007/s40262-017-0554-0
- Moore KT, Krook MA, Vaidyanathan S, Sarich TC, Damaraju CV, Fields LE. Rivaroxaban crushed tablet suspension characteristics and relative bioavailability in healthy adults when administered orally or via nasogastric tube. Clin Pharmacol Drug Dev 2014;3(4):321-7. https://doi.org/10.1002/cpdd.123
- Song Y, Chang M, Suzuki A, Frost RJ, Kelly A, LaCreta F, Frost C. Evaluation of Crushed Tablet for Oral Administration and the Effect of Food on Apixaban Pharmacokinetics in Healthy Adults. Clin Ther 2016;38(7):1674-1685 e1. https://doi.org/10.1016/j.clinthera.2016.05.004
- Song Y, Wang X, Perlstein I, Wang J, Badawy S, Frost C, LaCreta F. Relative Bioavailability of Apixaban Solution or Crushed Tablet Formulations Administered by Mouth or Nasogastric Tube in Healthy Subjects. Clin Ther 2015;37(8):1703-12. https://doi.org/10.1016/j.clinthera.2015.05.497
- Medscape. Drug interaction checker. https://reference.medscape.com/drug-interactionchecker.
- University of Liverpool. COVID-19 Drug Interactions - Prescribing resources. https://www.covid19-druginteractions.org/ (May 2, 2020; date last accessed).
- Westphal JF. Macrolide - induced clinically relevant drug interactions with cytochrome P-450A (CYP) 3A4: an update focused on clarithromycin, azithromycin and dirithromycin. Br J Clin Pharmacol 2000;50(4):285-95. https://doi.org/10.1046/j.1365-2125.2000.00261.x
- Faragon JJ, Budak JZ. National HIV curriculum. Section 3. Antiretroviral therapy/Topic 3. Drug Interactions with Antiretroviral Medications. https://www.hiv.uw.edu/go/antiretroviral-therapy/drug-drug-interactions/core-concept/all (February 7, 2020; date last accessed).
- Lipsitch M, Swerdlow DL, Finelli L. Defining the Epidemiology of Covid-19 - Studies Needed. N Engl J Med 2020;382(13):1194-1196. https://doi.org/10.1056/NEJMp2002125
- Emanuel EJ, Persad G, Upshur R, Thome B, Parker M, Glickman A, Zhang C, Boyle C, Smith M, Phillips JP. Fair Allocation of Scarce Medical Resources in the Time of Covid-19. N Engl J Med 2020. https://doi.org/10.1056/NEJMsb2005114
- Piepoli MF, Hoes AW, Agewall S, Albus C, Brotons C, Catapano AL, Cooney MT, Corra U, Cosyns B, Deaton C, Graham I, Hall MS, Hobbs FDR, Lochen ML, Lollgen H, Marques-Vidal P, Perk J, Prescott E, Redon J, Richter DJ, Sattar N, Smulders Y, Tiberi M, van der Worp HB, van Dis I, Verschuren WMM, Binno S, Group ESCSD. 2016 European Guidelines on cardiovascular disease prevention in clinical practice: The Sixth Joint Task Force of the European Society of Cardiology and Other Societies on Cardiovascular Disease Prevention in Clinical Practice (constituted by representatives of 10 societies and by invited experts)Developed with the special contribution of the European Association for Cardiovascular Prevention & Rehabilitation (EACPR). Eur Heart J 2016;37(29):2315-2381. https://doi.org/10.1093/eurheartj/ehw106
The document is not a guideline. The recommendations are the result of observations and personal experience from health care providers at the forefront of the COVID-19 pandemic. © The European Society of Cardiology 2020. All rights reserved.