Cardiovascular disease management

The Corona Virus Infective Disease of 2019 (COVID-19) has become a global scourge.It is usually asymptomatic but in symptomatic patients primarily causes pneumonia but can also affect other organs of the body- kidneys, heart and vascular system. Patients with risk factors for cardiovascular disease –Hypertension, Diabetes, Obesity, elderly male, as well as patients with preexisting cardiovascular disease, cerebrovascular disease, rheumatic heart disease and Myocarditis are particularly vulnerable with increased morbidity and mortality. Apart from venous and arterial thrombotic complications manifesting as venous thromboembolism and acute coronary syndromes, myocarditis can worsen the heart failure in patients with chronic heart failure.Besides mechanical cardiovascular complications, various electrical complications like arrhythmias may complicate the clinical condition in COVID-19, even causing sudden cardiac death.

Cardiac patients reporting to the emergency room need to be triaged based on the preexisting cardiovascular, respiratory, renal disease or cancer, any of which can cause severe complications if infected with corona virus. Special attention must be given to ensuring that there are separate facilities in place for dealing with COVID-19 cardiac patients and non-COVID-19 cardiac patients including catheterization laboratories.

In patients with preexisting Hypertension, already on ACE-I and ARBs (a group of antihypertensive), the same is to be continued as this group of drugs is said to be protective in COVID-19 patients.

In diabetic patients,close monitoring of blood sugar is required and uncontrolled diabetes makes the patient more vulnerable for COVID-19 and increased mortality.

Also read: Eating this bacterium may cut cardiovascular disease risk: Study

Patients with chest pain suggestive of Acute Coronary syndrome, presenting to the ER provide particular challenges for Cardiologists because “Troponins” — the substances that are present in the heart muscles and are released in the blood in the event of a heart attack — can be high in patients with COVID-19 who otherwise don’t havea heart disease. Such patients should be treated according to standard guidelines, with special precautions taken with those who have high fever and are at a higher risk for developing COVID-19.

In hospital standard operating procedures must be laid down on types of patient treatment and decisions on invasive procedures which are urgent or can be deferred. This requires a dedicated infrastructure for managing ACS in patients with suspected or COVID-19 positive test, and non COVID-19 patients. Testing for diagnosis of COVID-19 should be available at the same facilities that manage ACS patients.

Invasive procedures like angiography and angioplasty should be reserved for critical patients provided that the facility has systems in place for non-transmission of coronavirus during transport and treatment. Patients with stable hemodynamics can have deferred procedures.

If the hospitals have more than one catheterization lab, one lab could be designated for management of COVID-19 positive or suspected COVID-19 patients, with the strict sanitization process after managing each COVID-19 positive patient.

Any oral or surgical treatment to restore blood flow to the heart must also consider risk to medical personnel, staff availability and the number of high-dependency beds in a hospital. Along with risk from viral inflammation, cardiac patients also face the risk of plaque rupture in coronary arteries and drugs such as aspirin are indicated.

COVID-19 positive cases:

Patients with uncomplicated Heart attack, initial treatment with Thrombolysis (clot dissolving drug) should be done and if it fails then only cardiac catheterization should be done taking all safety precautions like PPE for all the staff and Negative pressure in catheterization laboratories.

Patients with large or complicated heart attack would likely require primary Coronary angioplasty instead of thrombolysis but risks to cath lab staff must be considered in taking this decision.

Patients with unstable angina should be treated conservatively and coronary angiography deferred till much after they become COVID negative.

Suspected COVID-19 cases:

Patients with uncomplicated heart attack should receive thrombolysis, as with patients who are confirmed as COVID-19 positive.

Unstable angina patients would not have full-blown treatment including invasive procedures but rather, more conservative management, pending COVID-19 test results. Timing is important so that results of COVID-19 tests can be integrated into planning and decision-making for control of infection.

COVID-19 patients can have a very low platelet count (platelets are responsible for stopping bleeding by helping blood to clot); this becomes a crucial consideration whether or not to perform procedure.

In case of Myocardities with or without heart failure, Current treatment guidelines for viral myocarditis should be applied, including the use of standard heart failure therapies and supportive measures. Prednisolone, a steroid, has shown some benefit in some of the myocarditis patients.

COVID-19 infection has been associated with abnormalities in blood clotting. Anticoagulation treatments with unfractionated and low molecular weight heparin to stop clotting could be beneficial.

Non COVID Heart patients should continue with Aspirin to prevent micro clots.

In heart failure patients with suspected or confirmed COVID-19 disease, respiratory infection is a common trigger of suddenly worsening symptoms. Patients with chronic cardiac conditions, including heart failure, are susceptible to respiratory infections and to the complications that can occur with overlapping signs and symptoms of both cardiac and respiratory conditions. The high virulence and transmissibility of COVID-19 requires for extra efforts to minimize exposure to both patients and medical staff.

Stable patients with chronic heart failure may be followed up via telemedicine as far as possible, with elective procedures deferred. Routine flu vaccination should be considered for patients with preexisting cardiac disease especially chronic heart failure.

Patients in unstable condition visiting the emergency room as well as healthcare workers at the facility must stick to the strictest safety measures such as adequate physical distancing, access to, and use of, personal protective equipment (PPE). Adapting infrastructure can necessitate sectioning off staff, wards and equipment as far as possible, and establishing patient front-facing versus non-patient-facing teams, COVID-19 positive versus negative patients wards to minimize cross-contamination, thorough disinfection of equipment used for patient evaluation, and limiting visitors but using virtual means to communicate with patients’ relatives as much as possible.

In the emergency room, initial clinical assessment should focus on history and physical examination, isolating patients until the diagnosis of COVID-19 is established or excluded and this may require repeated swab testing.

Standard investigations in the evaluation of HF patients should be considered with a number of limitations that range from conducting bedside assessments, requesting tests that affect management outcome, and with parameters for carrying out more technical, medical procedures at the same time keeping the safety of caregivers in mind.

Treatment of patients with heart failure and confirmed COVID-19 should include considerations that include, continuation of medical therapies.

The patients with Rheumatic Heart disease, when admitted for acute symptoms need to be treated primarily as other heart failure patients from diverse causes.

Patients requiring cardiac surgeries, if not an emergency, should defer the procedure. If an emergency, a negative Covid report should give a go ahead to the performing surgeon.

(Disclaimer: The author is Dr Vivek Kumar, Director Interventional Cardiology, Fortis Escorts Heart Institute, Okhla, New Delhi. Views expressed are a personal opinion.)

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