Cardiac Care and COVID-19: Perspectives in Medical Practice

PREFACE

The optimal management of patients with cardiac disease warrants a multifaceted approach undertaken in harmony. The recent decades have witnessed major advances in methods for monitoring and interventions aiming to improve outcomes in this outstanding cause of death worldwide. Other than technological improvements, the medical community is aware that this task can only be achieved via a mutual collaboration of doctors in the pre-hospital phase, hospital emergency departments, intensive care units, social studies, public health professionals, and bystanders.

For nearly a year, our lives have changed like never before. The current WHO clinical guide documents cite that ‘there is no current evidence to recommend any specific anti-COVID-19 treatment for patients with confirmed COVID-19’.

In order to overcome the pandemic with minimized global losses, the scientific community, healthcare facilities, professional organizations, chambers, and state institutions should work in coordination and unison. Most importantly, only a coordinated approach with all targeted masses reached via awareness programmes and campaigns can create a real difference in this pandemic era.

This project, of the book ‘Cardiac Care and COVID-19: Perspectives in Medical Practice’ is intended to encompass the advancements regarding diagnoses and treatment modalities for cardiac diseases in general and emergency cardiac conditions to be more specific, with respect to pandemic conditions. Apart from up-to-date descriptions of the problem and delineation of management principles, case examples were also used to highlight complex issues for a concrete understanding of the medical practitioner.

The ultimate objective is to provide a reference source with up-to-date information on the management of cardiac emergencies and resuscitation in the COVID-19 era. We aim to conduct a brief overview of epidemiological features of cardiac emergencies and their sociodemographic factors, measures to be taken for prevention, together with diagnostic and therapeutic procedures to pursue in the pandemic era.

CONSENT FOR PUBLICATION

Not applicable.

CONFLICT OF INTEREST

The author declares no conflict of interest, financial or otherwise.

ACKNOWLEDGEMENTS

Declared none.

Ozgur KARCIOGLU

Prof. FEMAT, Department of Emergency Medicine

University of Health Sciences

Istanbul Education and Research Hospital

Fatih, Istanbul

Turkey

Introduction: Cardiac Disease in the Pandemic Era: Teaching an Old Dog New Tricks?

Ozgur KARCIOGLU

Abstract

Nowadays, cardiac diseases, both developed de novo and acute exacerbations of chronic conditions, remain the most prominent death cause for the middle-aged and elderly, mostly in the developed, industrialized countries.

Since the end of 2019, COVID-19 pandemics have changed our lifestyles fundamentally, and maybe we will never find a way to return to the world of 2019. This catastrophic change had its impact on almost every aspect of our lives, including how we will manage cardiac arrest patients, how to perform perform cardiopulmonary resuscitation (CPR), ACLS, etc. A net effect is that protecting ourselves will take priority (more than before) in all procedures we pursue. Thus we can conclude that new generations should incorporate self-protecting behavior and techniques to benefit the patients in the most fruitful ways.

High-quality CPR cardiopulmonary resuscitation is among the most prominent issues to save humanity from the high burden of cardiac events. Relatively novel techniques such as mechanized devices for CPR, extracorporeal membrane oxygenation (ECMO), and therapeutic temperature management promise the highest possible solution to improve survival rates, in conjunction with urgent coronary angiography with revascularization.

Pandemics can be overcome not by the heroic behaviors of a few people but by the solidarity of society. The medical community should find the best solutions to help those in need with cardiac diseases even in pandemic conditions since this pandemic will not go away like magic. The aim of this book is to support patients and their next of kin, as well as health care workers, those who have dedicated themselves to healthy well-being with their relentless endeavor.

Keywords: Cardiac arrest, Cardiac arrhythmias, Cardiopulmonary resuscitation, COVID-19 pandemics, Defibrillation, Treatment.

Introduction

As an ageless phenomenon of life, medicine has been viewed as an art of recognizing and relieving human sufferings, treating diseases and wounds for ages. The last centuries have witnessed warfare, socioeconomic crises, and many

other threats which had a great impact on the medical database used and practicing ways in cardiac resuscitation.

Cardiovascular disease (CVD) is the leading cause of death for adults. Expedient diagnosis and prompt institution of treatment can save lives, especially during the deadliest cardiac emergencies, including sudden cardiac death, acute pulmonary edema, lethal arrhythmias, and acute pericarditis.

In order to establish an easier recognition and a more holistic, systematic approach to cardiac emergencies, revolutionary steps forward and developments in cardiac markers, monitoring, defibrillation, therapeutic hypothermia or temperature management (TTM), capnographic recordings, and the like were developed after 60’s and 70’s. Now we can postulate that these innovations must have mitigated the hazards of cardiac diseases globally. Maybe this is why cancer and infectious diseases are championing on the morbidity and death list in most parts of the world in the last decades.

The most prominent death scenario comprises out-of-hospital cardiac arrest (OHCA) in the middle-aged population globally. Lethal dysrhythmias can be divided into four types: ventricular fibrillation-VF, pulseless ventricular tachycardia (PVT), asystole, and pulseless electrical activity, which are responsible for impaired cardiac functioning and even sudden cardiac death.

VF is one of the most deadly cardiac arrhythmias and certainly the most common one. It can be described as the erratic, disorganized firing of impulses from the ventricles, producing no palpable pulses in the periphery. Literature data have shown that the earlier defibrillation and bystander cardiopulmonary resuscitation (CPR) are commenced, the lower is the patient mortality. Since considerable differences can affect people’s lives in this context, the role of medical command bears utmost importance to direct these patients to facilities with discrete capabilities

VF is among the most common and fatal cardiac arrhythmias. Literature findings demonstrated that patient mortality could be much lower when defibrillation is performed early and when laypeople initiate cardiopulmonary resuscitation (CPR). As important differences in this process can have an impact on our lives, the role of the EMS medical command is of great significance in directing these patients to facilities with adequate levels of resources (Stoecklein, 2018).

Emergent Coronary Revascularization

Emergent Coronary Revascularization is an outstanding life-saving intervention in patients with acute coronary syndromes, mostly AMI.

Alternative Approaches to the Management of VF

Most patients with refractory VF are resistant to conventional treatment strategies. Nonetheless, some new techniques produced promising outcomes (Bell, 2018). Of note, double sequential defibrillation can represent an option for the conventional approach for the treatment of PVT or refractory VF (Simon, 2018).

Recently, procedures like extracorporeal life support and bedside ultrasound have been launched. These may represent a logical and practical way to manage patients with refractory arrest rhythms, both in-hospital and out-of-hospital milieu. Likewise, drones have been introduced as one of the contemporary advances, to bring automated external defibrillators (AED) to the patient with OHCA. Also, digital and mobile technology have launched new apps to optimize interventions carried out by laypeople, to increase survival in this group of patients with poor expectancy for return of spontaneous circulation (ROSC) (Latimer et al., 2018).

A major challenge for contemporary medicine as a whole is operating a system focused on the optimized outcomes of patients with OHCA. This challenge can only be overcome with a flexible and resourceful approach that comprises various teams, from call receivers, monitors, to emergency medical service (EMS) staff and the healthcare workers in the receiving center (McCoy et al., 2018). The application of these techniques for OHCA in a healthcare system will yield the most favorable outcomes for survivors without sequelae among well-known or ‘classical’ approaches.

A majority of the current management guidelines to improve survival following arrest situations are the result of efforts to improve CPR quality, increasing the chances of ROSC and the like. The emphasis on the delivery of proven techniques and the reliable implementation of these strategies through the measurement and audit of quality improvement strategies will create a foundation so that innovations in resuscitation could be designed and planned (Reed-Schrader, 2018). After all those above mentioned important developments, post-cardiac arrest interventions have aroused more curiosity. Therapeutic hypothermia or TTM, which has become the state-of-art in most hospitals, will produce the best probability of relief after the ROSC without remarkable sequelae (Walker, 2018).

The Pandemics

This catastrophic change had its impact on almost every aspect of our lives, including how we should manage cardiac arrest patients, how to perform CPR, ACLS, etc. Bugger et al. investigated the net effect of the pandemic restrictions on certain major cardiovascular emergencies (myocardial infarction, pulmonary thromboembolism, and aortic dissection) in Austria (Bugger et al. 2020). Although it was a retrospective registry-based study, the authors highlighted the reductions of admission rates related to these three entities. The total numbers of admissions due to the three major emergency conditions during the pandemic restrictions were below the corresponding figures in the previous years (RR 0.77, p<0.001). This decrease has been postulated to be mainly caused by lower acute coronary syndrome admissions (RR 0.77, p = 0.004).

COVID-19 has killed more than 1.600.000 people worldwide – and the total of officially reported cases has surpassed 70 million. However, we should all realize that COVID-19 is not the last epidemic. It is obvious that there will be new generations and our long years to spend with masks, sanitizers and hand disinfectants. In the long run, it is important to organize efforts to perform selective admissions to health institutions, in order to overcome overcrowdedness.

To be more specific, the education of pre-school and school children and women plays a key role to increase family awareness. The threat of the pandemic disease should be concretized, so that the lifestyles of the peoples will adapt to the new normal. Such a great breakthrough will mandate organized efforts, both by the governments and civil society (Fig. 1).

Fig. (1))

Immediately after the first phase reflecting sudden illness and mortality resulting from COVID-19, the lack of resources and the consequences of the restrictions for the patients with non-COVID serious illnesses. The 3rd wave depicts the long-term consequences of the lack of care of chronic diseases, and finally, the individual and social psychological effects and related trauma are described in the fourth phase.

Conclusion

Cardiac disease, both developed de novo and acute exacerbations of chronic conditions remain the most prominent death cause for the middle-aged and elderly, mostly in the developed, industrialized countries. Medical community should find the best solutions to help those in need with cardiac diseases even in the pandemic conditions, since this pandemic will not go away like a magic.

The objective of this manuscript is to enlighten ways to recognize and devise interventions for acute cardiac diseases, along with creating novel techniques for state-of-the-art resuscitative measures.

References

Cardiovascular Disease and COVID-19

Ozgur KARCIOGLU

Abstract

Cardiovascular disease (CVD) has long been the leading cause of global morbidity and mortality. However, with the COVID-19 pandemic, which has been the focus of attention all over the world since the end of 2019, this issue has gained different importance. The presence of CVD leads to more severe COVID-19 and an increased probability of mortality. In addition, both CVD and COVID-19 pave the way to myocardial injury, which also boosts the morbidity and death toll. Another point is the possible deprivation of usual healthcare received by cardiac patients (CVD and others) because of the shifted emphasis of the hospital and prehospital medical services on COVID-19. As the public can foresee that the pandemic will not disappear rapidly soon, healthcare organization faces a challenge to be redesigned radically. The objective of this chapter is to analyze CVD, myocardial injury, and other cardiac diseases resulting from COVID-19 itself, together with the impact of the pandemics on the usual healthcare of cardiac patients.

Keywords: Acute myocardial infarction, Cardiovascular disease, Coronavirus, COVID-19, Diagnosis, Treatment.

INTRODUCTION

Acute coronary syndromes (ACS) is a general term for conditions that occur as a result of a sudden blockage of the blood flow to the heart. These syndromes range from potentially reversible unstable angina (UA) phase to irreversible cell death from myocardial infarction (MI), including non-ST elevation myocardial infarction (NSTEMI) or ST-elevation myocardial infarction (STEMI).

Distinguishing Features of Acute Coronary Syndromes

UA, NSTEMI, and STEMI have a common pathophysiological origin of atherosclerotic coronary artery disease (CAD), which is characterized by plaque formation on the walls of arteries that supply blood flow to the heart. Erosion or rupture of the plaque leads to a blood clot (thrombosis) that blocks blood flow to the heart, depriving the heart of oxygen and consequently leading to myocardial necrosis (tissue death in the heart muscle).

Cardiovascular disease (CVD) has been associated with viral infections or outbreaks for decades. It has been reported that approximately half of COVID-19 patients have CVD, and this rate increases to 70% in intensive care units (ICU) (Zhou et al., 2020, Wang et al., 2020). It is known that 50% of the cases with Middle-East Respiratory Syndrome (MERS) infection in 2012 had DM and HT, and 30% had CVD (Badawi et al., 2016). Meanwhile, certain CV risk factors have been thought to affect the clinical course of COVID-19 (Table 1).

Table 1 CV risk factors that are thought to affect the clinical course of COVID-19.

Findings From Different Database Studies

In the study which analyzed 5700 patients in New York, frequency of hypertension (HT) was reported as 56.6%, obesity 41.7%, DM 33.8%, CAD 11.1%, and congestive heart failure (CHF) 6.9% (Richardson et al., 2020). In the study that included more than 72,000 patients in China, 12.8% HT, 5.3% DM, 4.2% CVD were found. The frequency of comorbidity is similar in industrialized countries, except that the HT, metabolic disorders, and obesity rates are significantly higher than in the far east, but the prevalence varies considerably.

When analyzing 22,254 patients who were screened with PCR tests between 5 March and 9 April in NYC, at least one comorbid disease was reported in about half of those with positive tests (46%) (Kalyanaraman Marcello, 2020). In the sample, 33% diabetes, 37% HT, 24% CVD, 11% chronic renal failure (CRF) were noted. Among the hospitalized patients, 28% died. Male gender, age, DM, history of heart disease, presence of CRF are risk factors for both test positivity and death.

In a case series from Detroit, Suleyman et al. searched for independent risk factors for admission to intensive care units: being over the age of 60, male sex, HT, DM, CRF, severe obesity (BMI>= 40), and cancer were reported to be the ones (Suleyman et al., 2020). Smoking was also higher in hospitalized patients. Admissions due to dyspnea, tachypnea, or hypoxia also increases the risk of hospitalization. Fever increases the likelihood of hospitalization but does not predict poor outcomes in patients with COVID-19. Inflammatory markers were also found higher in those hospitalized in ED when compared to those discharged from ED.

Respiratory failure developed in 74% of those hospitalized in ICU, and MV was required in 81% of these. 25% of those hospitalized had to be transferred to ED. The majority of those who received MV under 40 years of age (62.5%) had severe obesity, while only 26% of those who did not need MV had the condition. Mortality in ICU was 40%, and 7% in all those hospitalized. 45.6% of those who require MV died of severe complications.

Are Ethnic Differences Important for COVID-19?

Marcello et al. conducted a study that analyzed more than 22,000 patients in NYC and reported that 26% of COVID-19s were black, and 34% were Hispanic (Marcello et al., 2020). They reported that comorbidities are more common in ethnic groups than others, but being black or Hispanic after adjustments is not directly related to positive PCR testing or death.

In another cohort reported from Louisiana, it is stated that blacks, which make up only 31% of the population, constitute 77% of the COVID-19 patients who are admitted into the hospital, but being black is not an independent risk factor when confounding factors are excluded (Price-Haywood et al., 2020). 70.6% of the dead are black.

Myocardial Injury Severity and Mortality

Autopsy showed interstitial mononuclear inflammatory cell infiltration in the myocardium (Xu, 2020). Also, markers showing myocardial damage increase with COVID-19 (Xu 2020, Guo 2020, Shi, 2020). Shi et al. reported that myocardial damage was close to 20% in patients who died (Shi, 2020). Moreover, cardiac damage is the risk factor that affects mortality most strongly and independently (hazard ratio: 4.26). Guo et al. reported that high troponin levels accompanied significantly increased mortality (Guo, 2020).

In the series of Guo et al., which included 187 patients with COVID-19, they stated that there was a better clinical course in patients with CVD and no acute myocardial injury compared to those with both. For example, mortality in patients with fulminant myocarditis is between 40% and 70% (Caforio 2013. Ammirati 2019).

How Much Myocardial Damage Occurs in COVID-19?

In many studies, the myocardial damage has been reported to increase in parallel with the severity of the COVID-19 infection. He et al. demonstrated that more than half of the patients diagnosed with COVID-19 hospitalized in China in February 2020 had myocardial damage (He et al., 2020). This has been shown to have a direct affect in-hospital mortality (61% vs. 25%). In the study, levels of CRP and BNP were significantly higher (3 times or more) in those with myocardial damage than those of the others.

Chen et al. revealed that the disease is closely related to myocardial damage in their analysis on 150 COVID-19 cases (Chen et al, 2020). High levels of cTnI and the development of CHF have been disclosed as independent risk factors for myocardial damage.

In Whom does Myocardial Damage Occur and How do we Identify it?

Myocardial damage is more common in older people with COVID-19 and those with increased TnT levels (Shi et al. 2020, Guo et al. 2020). Although TnT levels are normal in these patients, HT, CAD, CHF and DM are more common than others.

While COVID-19 infects the alveoli in the lung and triggers obstruction in the small airways, it can also affect the vessels, causing damage to the heart, kidney and nervous system, intestines and liver. For example, protein or blood cells may be detected in the urine in every second patient. It was also stated that hemodialysis was performed in 14% to 30% of the intensive care patients with COVID-19 in Wuhan. It is postulated that all this damage cannot be explained only by ‘storming cytokines’.

In patients with COVID-19, death usually occurs from multiple organ failure, and it can be difficult to distinguish between myocardial damage and other organ failure syndromes. Myocardial damage occurs in patients with cardiac dysfunction and ventricular dysrhythmias.

Guo et al. reported that 28% of 187 COVID-19 patients had myocardial damage (Guo et al., 2020). He et al. raised the bar, and showed that 50% of 54 patients with COVID-19 diagnosed in China in February 2020 had myocardial damage (He, et al. 2020).

Bansal et al. reported that acute cardiac damage was present in 8% to 12% of all COVID-19 cases as a result of the literature review (Bansal, et al. 2020). Systemic inflammation and direct viral involvement contribute to cardiac injury. Presence of CVD and acute cardiac damage significantly accompany significant deterioration.

Pathological Findings

SARS-CoV-2 positivity in cardiac tissue as well as CD3+, CD45+, and CD68+ cells in the myocardium and gene expression of tumor necrosis growth factor α, interferon γ, chemokine ligand 5, as well as interleukin-6, -8, and -18 were identified in autopsy cases died of COVID-19 (Lindner et al., 2020). Cardiac tissue from 39 consecutive autopsy cases were analyzed (median age: 85) SARS-CoV-2 could be documented in 24 of 39 patients (61.5%). Of note, there was no significant difference regarding inflammatory cell infiltrates or leukocyte numbers per high power field between those with a diagnosis of COVID-19 and those without. These findings suggest that among individuals with COVID-19, overt myocarditis may not be identified in the acute phase, but the long-term consequences of this cardiac infection needs to be elucidated.

Global View of Myocardial Infarction (STEMI/NSTEMI) After COVID-19

Due to the serious increase in COVID-19 cases all over the world, the health system is concerned that the other (non-COVID-19) patients will be ignored when its focus has shifted while the whole system faces a serious healthcare burden.

Very interesting data were obtained from the world in this regard. In Hong Kong, Tam et al. shared data which indicated that the ‘speed of care’ was severely affected after COVID-19 in STEMI cases (Tam, et al. 2020). In Hong Kong, there was a rapid increase in the duration of the ambulance reaching to the patient (Symptom onset to first medical contact) from 80-90 minutes to 318 minutes after the call. This raises a concern that healthcare system in the COVID-19 era may not be able to care for cardiac emergencies adequately due to the burden and chaos it brings to most institutions.

Diagnostic Strategies

In the pandemic period, invasive procedures necessitating close contact with the patient carry a high risk for disease transmission. Thus, additional non-invasive evaluation is required in the ED to verify the diagnosis, as STEMI cases can also be admitted with atypical symptoms and signs. In this way, both COVID-19 risk classification is made and the diagnosis is tried to be clarified in terms of STEMI. Myocardial wall movement deficits are evaluated by POCUS or bedside echocardiography. The diagnosis is clarified by clinical examination, ECG, laboratory (enzyme elevation), and imaging data. Coronary CT-angiography can be considered, for example, where ECG and echocardiography are vague and the patient is stable. Activation of the catheterization laboratory should be considered immediately thereafter.

Myocarditis, which is more common in viral infections such that in the COVID-19 period, may also mimic STEMI. Among patients with COVID-19, death was found to be significantly more common in patients diagnosed with myocarditis.

Treatment Strategy: PCI or Fibrinolysis?

The standard method for STEMI patients during the pandemic period will be the primary PCI within the appropriate time frame (Mahmud et al., 2020). In all cases, catheterization should be considered as a priority in the management of hemodynamic unstable patients. For this procedure, PPE should be fully worn and the intervention applied in a specially designed and adapted catheter laboratory.

On the other hand, some centers advocate that fibrinolysis can represent a reasonable alternative for patients with STEMI during the COVID-19 pandemic, especially because of the agents’ considerable efficacy and safety and advantages in conserving medical resources (Wang, 2020). In this small but well-designed comparison study, fibrinolysis achieved a comparable in-hospital and 30-day primary composite end point in those with STEMI, as compared with those who underwent PPCI during the COVID-19 pandemic. No major bleeding episode was recorded in either group. In the USA, the consensus document published with associations of cardiologists and emergency physicians stated that fibrinolytic-based strategies will be developed in cases where PCI cannot be implemented or the timing will not be correct (Mahmud, 2020) (Fig. 1).

Respiratory decompensation in intubated cases with severe COVID-19 in whom ARDS is also in the differential diagnosis should be evaluated on a case-by-case basis. There should be a critical assessment as to whether the patient will benefit from an invasive approach to have an impact on life expectancy.

Did the Pandemic Process Affect Heart Attacks?

Yes, a lot. Italian researchers reported that the number of patients with STEMI or NSTEMI admitted to the catheter laboratory during the COVID-19 epidemic period decreased significantly,