A 3-D rendering created from the chest CT scan of a 41-year-old coronavirus patient in China showing ground-glass opacities in several areas of the lungs from the coronavirus pneumonia. This was from one of the first medical imaging studies published on COVID-19 in the journal Radiology.
(Article updated May 27, 2020)
February 20, 2020 — The American College of Cardiology (ACC) released a clinical bulletin addressing the cardiac implications of the novel coronavirus (COVID-19, also referred to as SARS‐CoV‐2, 2019-nCoV and Wuhan Coronavirus). The key message to clinicians is that patients with underlying cardiovascular disease may have a potential increased risk if they contract coronavirus.
The bulletin provides background on the epidemic, which was first reported in late December 2019, and looks at early cardiac implications from case reports. It also provides information on the potential cardiac implications from analog viral respiratory pandemics and offers early clinical guidance given current 2019-nCoV uncertainty.
In particular, the bulletin notes that “in geographies with active 2019-nCoV transmission (mainly China), it is reasonable to advise patients with underlying cardiovascular disease of the potential increased risk and to encourage additional, reasonable precautions.” It stresses the importance for cardiovascular disease patients to “remain current with vaccinations, including the pneumococcal vaccine given the increased risk of secondary bacterial infection” and suggests encouraging the “influenza vaccination to prevent another source of fever which could be initially confused with coronavirus infection.”
Watch the VIDEO: What Cardiologists Need to Know about COVID-19 — Interview with Thomas Maddox, M.D., chair of the ACC committee that created the document.
Cardiac Implications of Novel Coronavirus:
The ACC lists the following points regarding early cardiac implications from case reports on Wuhan Coronavirus.
• Early case reports suggest patients with underlying conditions are at higher risk for complications or mortality from COVID-19; up to 50 percent of hospitalized patients have a chronic medical illness.
• 40 percent of hospitalized patients with confirmed COVID-19 patients have cardiovascular or cerebrovascular disease.
• In a recent case report on 138 hospitalized COVID-19 patients, 19.6 percent of patients developed acute respiratory distress syndrome.
• 16.7 percent of patients developed arrhythmia; 7.2 percent developed acute cardiac injury.
• 8.7 percent of patients developed shock; 3.6% developed acute kidney injury.
• Rates of complication were universally higher for ICU patients.
• The first reported death was a 61-year-old male, with a long history of smoking, who succumbed to acute respiratory distress, heart failure and cardiac arrest.
• Early, unpublished first-hand reports suggest at least some patients develop myocarditis.
Kawasaki-like Inflammatory Disease Affects Children With COVID-19
(updated May 27, 2020) A new, serious COVID-19 cardiovascular presentation emerged in late April and early May 2020 in the form of pediatric multi-system inflammatory syndrome, which includes features similar to Kawasaki disease. It was first reported in the United Kingdom and then cases began to appear in New York City and elsewhere in the United States.
The U.S. Centers for Disease Control (CDC) first issued a health advisory statement on the new COVID-19 (SARS-CoV-2) presentation May 14. The CDC is calling the new presentation in kids multi-system inflammatory syndrome in children (MIS-C). The CDC called for healthcare providers report any patient who meets the case definition to local, state and territorial health departments so data can be collected to enhance knowledge of risk factors, pathogenesis, clinical course and treatment of this syndrome.
Rapid Drop in Heart Attacks and Stroke at Hospitals Concerns ACC
(Update from April 14, 2020) — Since the start of COVID-19 containment efforts across the U.S. in March 2020, there has been a massive drop in the normal number of heart attack and stroke cases showing up at hospitals across the country. This has raised concerns that patients are not seeking medical attention because of fears about going to the hospital. Early staticics from Ital;y, Spain and the U.S. indicate up to a 35-40 percent drop in stroke and STEMI cases since containment efforts bagn in each country.
American College of Cardiology (ACC) is now urging people with what appear to be heart attack and stroke symptoms to seek medical help. The ACC said statistics for emergency rooms (ER) visits show major drops in heart attack, stroke amid the COVID-19 pandemic. The ACC is offering new CardioSmart resources outline to help patients determine when and how to seek help.
COVID-19 Very Similar to MERS and SARS
COVID-19 is a betacoronavirus, like severe acute respiratory syndrome (SARS) and Middle East respiratory syndrome (MERS), and presenting as viral pneumonia with a wide range of acuity, the bulletin states. As of Feb. 12, COVID-19 appears to have greater infectivity rate, but a lower case fatality rate, when compared to SARS and MERS. The ACC noted 99 percent of all coronavirus cases are in mainland China, where despite aggressive containment efforts, case counts continue to rise rapidly. Get up-to-date daily statistics from the World Health Organization (WHO) COVID-19 situation reports.
How to Manage AMI Patients During the COVID-19 Pandemic
(Updated April 22, 2020) — The Society for Cardiovascular Angiography and Interventions (SCAI), along with the American College of Cardiology (ACC) and American College of Emergency Physicians (ACEP) issued a consensus statement that provides recommendations for a systematic approach for the care of patients with an acute myocardial infarction (AMI) during the novel coronavirus (COVID-19, SARS-CoV-2) pandemic. The document is jointly published in Catheterization and Cardiovascular Interventions, the official journal of SCAI, and the Journal of the American College of Cardiology (JACC).
According to recent studies, cardiovascular disease patients who develop COVID-19 have a higher risk of mortality. However, many patients in need of care for the management of various heart diseases may not be infected with this coronavirus. The document identifies several challenges in providing recommendations for ST-elevation myocartdial infarction (STEMI) care during the COVID-19 epidemic. These include:
• Cardiovascular manifestations in the COVID-19 patient are complex and variable.
• The prevalence of COVID-19 in U.S. populations remains unknown.
• Personal protection equipment (PPE) is not uniformly available.
New York City Physicians Note Multiple Cardiovascular Presentations of COVID-19
(Update from April 8, 2020) — Research to help increase awareness of the cardiovascular manifestations of COVID-19 disease and the adverse impact of cardiovascular involvement on prognosis was published in Circulation April 3, the journal of the American Heart Association (AHA). In the article "The Variety of Cardiovascular Presentations of COVID-19," the team of 18 New York City physicians note novel coronavirus (COVID-19, SARS-CoV-2) can involve the cardiovascular system in a variety of ways.
The researchers said there are evolving considerations for treatment across the spectrum of patients with pre-existing cardiovascular diseases. The researchers also detail four case studies of patients to illustrate the multiple cardiovascular presentations of COVID-19 infection.
• In patients presenting with what appears to be a typical cardiac syndrome, COVID-19 infection should be in the differential during the current pandemic, even in the absence of fever or cough.
• One should have a low threshold to assess for cardiogenic shock in the setting of acute systolic heart failure related to COVID-19. If inotropic support fails in these patients, we consider IABP (intra-aortic balloon pump) as the first line mechanical circulatory support device because it requires the least maintenance from medical support staff.
• When patients on veno-venous extracorporeal membrane oxygenation (VV ECMO) for respiratory support develop superimposed cardiogenic shock, the addition of an arterial conduit at relatively low blood flow rates may provide the necessary circulatory support without inducing LV distension. Our experience confirms that rescue of patients even with profound cardiogenic or mixed shock may be possible with temporary hemodynamic support at centers with availability of such devices.
• COVID-19 infection can cause decompensation of underlying heart failure, and may lead to mixed shock. Invasive hemodynamic monitoring, if feasible, may be helpful to manage the cardiac component of shock in such cases.
• Medications that prolong the QT interval are being considered for COVID-19 patients and may require closer monitoring in patients with underlying structural heart disease.
• Our heart transplant recipient exhibited similar symptoms of COVID-19 infection as compared to the general population. For those transplant patients requiring hospitalization, how to alter the anti-metabolite and immunosuppression regimens remains uncertain.
• Furthermore, the COVID-19 pandemic creates a challenge for the management of heart failure patients on the heart transplant waitlist, forcing physicians to balance the risks of delaying transplant with the risks of donor infection and uncertainty regarding the impact of post-transplant immunosuppression protocols.
Cardiac Imaging Best Practices During the COVID-19 Pandemic
(Updated May 27, 2020 ) Cases of acute cardiovascular disease and cardiac complications caused by COVID-19 require cardiovascular imaging require cardiac imaging to continue under the pandemic. All the key cardiovascular imaging societies in March ands April issued COVID-19 guidelines and lists of considerations for how to continue imaging operations safely under the threat of viral contamination during the duration of containment efforts.
Common themes in all the recommendations from all the societies include:
• A screening checklist.
• Examples of how to triage patients for cardiology studies.
• Employ social distancing.
• Rescheduling non-urgent visits.
• Rescheduling elective surgeries and procedures.
• Using separate spaces for patients with known or suspected COVID-19 to prevent spread.
• Ensuring supplies are available.
• Promoting use of telehealth.
• Screen staff, patients and visitors before they enter the department.
• Minimize non-essential visitors into the department.
• Record symptoms at the start of the shift.
• Record temperature daily as per local policies and standards.
• Use personal protective equipment (PPE) for healthcare personnel.
• If available, use PPE for patients (due to concern of asymptomatic transmission of COVID-19).
• Maintain strict hand hygiene.
• Maintain 6 feet distance in all patient/staff interactions when possible.
• Minimize crowding in workplace.
• Work remotely whenever feasible.
• Use of virtual conference tools for meetings and educational conferences.
• Rotating staff schedules for on-site and off-site work.
• Training in local infection control recommendation.
Additional 2019-nCoV Information Available in the ACC Bulletin
The ACC said 2019-nCoV is a fast-moving epidemic with an uncertain clinical profile and providers should be prepared for guidance to shift as more information becomes available. The ACC said it will be updating the bulletin as appropriate. In addition, ACC has reached out to its partners and colleagues in China expressing its support as they work to address the growing epidemic.
The bulletin includes sections covering:
• Clinical guidance given current COVID-19 uncertainty;
• Potential cardiac implications from analog viral respiratory pandemics;
• Early cardiac implications from case reports on Wuhan Coronavirus; and
• Background on Coronavirus epidemic.
The bulletin was reviewed and approved by the ACC Science and Quality Oversight Committee.
CDC Delaying Spread to U.S. But Says it is Coming
The Centers for Disease Control and Prevention (CDC) said at a Feb. 21 press conference it is working to contain the spread of the novel coronavirus (COVID-19) into the United States, but said it is unlikely to do so. The agency said it hopes to slow the spread of the virus to enable more time for the U.S. healthcare system to prepare for its arrival.
“We never expected we’d catch every traveler with novel coronavirus from China. It would be impossible,” said Nancy Messonnier, M.D., the director for the National Center for Immunization and Respiratory Diseases. “We’re not seeing spread here in the United States yet, but it is possible, even likely, that it may eventually happen. Our goal continues to be slowing the introduction of the virus into the U.S. This buys us more time to prepare our communities for more cases and possibly sustained spread.”
She said this new virus represents a tremendous public health threat. “We don’t yet have a vaccine for this novel virus, nor do we have a medicine to treat it specifically. We are taking and will continue to take aggressive action to reduce the impact of this virus, and that it will have on the communities in the U.S.,” Messonnier said.
Seasonal Flu vs. Coronavirus Infection and Mortality Rates
As of Feb. 19, the World Health Organization reported 75,204 confirmed cases of coronavirus worldwide. Only 924 of these cases are reported outside China in 25 countries. There have been 2,006 COVID-19 deaths. All but three of these were in China. Reports show the death rate is about 2.3 percent.
A single center study of 138 patients diagnosed with COVID-19 in Wuhan, China, said 26 percent of patients required admission to the intensive care unit and 4.3 percent died. The study also said presumed human-to-human hospital-associated transmission of SARS‐CoV‐2 was suspected in 41 percent of patients.
Another study published Feb. 20 for 121 symptomatic patients infected with coronavirus said about 20 percent of cases are severe and mortality is approximately 3 percent.
For comparison with seasonal flu in the United States, Centers for Disease Control and Prevention (CDC) estimates that so far this season there have been at least 26 million flu illnesses. The CDC said there have been about 250,000 hospitalizations and 14,000 deaths so far from flu. The CDC said the percentage of deaths attributed to pneumonia and influenza is 6.8 percent, which the CDC said is below the epidemic threshold of 7.3 percent.
UPDATED INFORMATION from April 22, 2020: COVID-19 (SARS-CoV-2) cases reported are as follows:
• 2,593,129 worldwide diagnosed cases
• 827,038 diagnosed cases in the U.S.
• 45,525 U.S. deaths
• Mortality rate range for U.S cases between 2-7.5 percent, but are consistently between 6-10 percent in patients with various comorbitities
• The CDC reported April 16, 2020, 18.8% of all deaths occurring during the week ending April 11, 2020 (week 15) were due to pneumonia, influenza or COVID-19 (PIC). This percentage is above the epidemic threshold of 7% for week 15 and has been increasing sharply since the end of February.
Related COVID-19 Cardiology Content:
VIDEO: What Cardiologists Need to Know about COVID-19 — Interview with Thomas Maddox, M.D.
VIDEO: Overview of Hydroxychloroquine and FDA Warning in its use to Treat COVID-19 — Interview with Marianne Pop, Pharm.D.
VIDEO: Multiple Cardiovascular Presentations of COVID-19 in New York — Interview with Justin Fried, M.D.
VIDEO: CT and POCUS Emerge As Frontline Cardiac Imaging Modalities in COVID-19 Era — Interview with Geoffrey Rose, M.D.
VIDEO: COVID-19 Precautions for Cardiac Imaging — Interview with Stephen Bloom, M.D.
VIDEO: Best Practices for Nuclear Cardiology During the COVID-19 Pandemic — Interview with Hicham Skali, M.D.
Additional Coronavirus Resources for Clinicians:
1. Mohammad Madjid, Scott D Solomon, Orly Vardeny. ACC Clinical Bulletin Cardiac Implications of Novel Wuhan Coronavirus (COVID-19). American College of Cardiology (ACC). Published online Feb 12, 2020. https://www.acc.org/~/media/665AFA1E710B4B3293138D14BE8D1213.pdf. Accessed Feb 20, 2020.
2. Chen H, Zhou M, Dong X, et al. Epidemiological and Clinical Characteristics of 99 cases of 2019 novel coronavirus pneumonia in Wuhan, China: a descriptive study. Lancet 2020; published online Jan 29. https://www.thelancet.com/action/showPdf?pii=S0140-6736%2820%2930211-7.
3. Wang D, Hu B, Hu C, et al. Clinical Characteristics of 138 Hospitalized Patients with 2019 Novel Coronavirus-Infected Pneumonia in Wuhan, China. JAMA. Published online Feb. 07, 2020. doi:10.1001/jama.2020.1585
4. Coronavirus disease 2019 (COVID-19) Situation Report – 30. World Health Organization (WHO). Published online Feb. 19, 2020. https://www.who.int/docs/default-source/coronaviruse/situation-reports/20200219-sitrep-30-covid-19.pdf?sfvrsn=3346b04f_2. Accessed Feb. 20, 2020.
5. Adam Bernheim , Xueyan Mei, Mingqian Huang, Yang Yang, et al. Chest CT Findings in Coronavirus Disease-19 (COVID-19): Relationship to Duration of Infection. Radiology.
Published Online Feb 20, 2020. https://doi.org/10.1148/radiol.2020200463. Accessed Feb 20, 2020.