Sandbox:Sara Haddadi

1. Sara Haddadi MD, Miami FL

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Acute Cough

History and physical examination, ask about environmental and occupational factors and travel exposures ± investigations

Life-threatening diagnosis

Non-life-threatening diagnosis

Pneumonia, severe exacerbation of asthma or COPD, PE, heart failure, other serious disease

Infections

Exacerbation of pre-existing condition

LRTI

URTI

Asthma

Bronchiectasis

UACS

COPD

Evaluate and treat first

Acute Bronchitis

Pertussis

Consider TB in endemic areas or high risk

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Acute Cough

History and physical examination, ask about environmental and occupational factors and travel exposures ± investigations

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D02' D02

LRTI

URTI

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Z

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Natural History, Complications and Prognosis

In a case series with 187 patients who had confirmed COVID-19, 27.8% of patients had a myocardial injury, which caused cardiac dysfunction and arrhythmias. The result was significantly higher mortality among patients with myocardial injury.

• Based on the Troponin level The mortality during hospitalization was shown to be as below:
  • 7.62% for patients without underlying CVD and normal TnT levels
  • 13.33% for those with underlying CVD and normal TnT levels
  • 37.50% for those without underlying CVD but elevated TnT levels
  • 69.44% for those with underlying CVD and elevated TnTs.

Classification of Infra-Hisian Block

Types of Infra-Hisian Block	Sub-type
Type 2 second degree heart block (Mobitz II)	_
Left bundle branch block	Left anterior fascicular block
Right bundle branch block	_

Covid19. [1] underlying medical conditions that increase a person’s risk of severe illness from COVID-19 Level of Evidence Condition Strongest and Most Consistent Evidence Serious heart conditions, such as heart failure, coronary artery disease, or cardiomyopathies Cancer Chronic kidney disease COPD Obesity (BMI> 30) Sickle cell disease Solid organ transplantation Mixed Evidence Left anterior fascicular block Limited Evidence _ Blood disorders Chronic kidney disease Chronic liver disease Compromised immune system (immunosuppression) Current or recent pregnancy in the last two weeks Endocrine disorders Metabolic disorders Heart disease Lung disease Neurological and neurodevelopmental conditions CDC has published the following conditions listed in the table below as the risk factors for a severe COVID-19. These conditions are categorized into the following groups based on the current studies evidence: Strongest and most consistent evidence: define as consistent evidence from multiple small studies or a strong association from a large study are categorized. They increase the severity of COVID-19 regardless of the individual's age: Mixed evidence: Defined as multiple studies that reached different conclusions about the risk associated with a condition Limited evidence: Defined as consistent evidence from a small number of studies. Limited evidence: Defined as consistent evidence from a small number of studies. underlying medical conditions that increase a person’s risk of severe illness from COVID-19 Level of Evidence Condition Strongest and Most Consistent Evidence Serious heart conditions, such as heart failure, coronary artery disease, or cardiomyopathies Cancer Chronic kidney disease COPD Obesity (BMI> 30) Sickle cell disease Solid organ transplantation Type 2 diabetes mellitus Mixed Evidence Asthma Cerebrovascular disease Hypertension Pregnancy smoking Use of corticosteroids or other immunosuppressive medications Limited Evidence Bone marrow transplantation HIV Immune deficiencies Inherited metabolic disorders Liver disease Neurologic conditions Other chronic lung diseases Pediatrics Thalassemia Type 1 diabetes mellitus This list is a living document that will be periodically updated, and it could rapidly change as the science evolves. References

6/20/2020

Acute Coronary Syndromes

Pathophysiology

The mechanism of COVID-19 cardiovascular injury has not been fully understood and is likely multifactorial.

• SARS-CoV-2 virus attaches to ACE 2 protein for ligand binding before entering the cell via receptor-mediated endocytosis.
  • Based on single-cell RNA sequencing more than 7.5% of myocardial cells have positive ACE2 expression. This protein can mediate the entry of SARS-CoV-2 and result in direct cardiotoxicity.
• The cytokine release caused by the virus may lead to vascular inflammation, plaque instability, myocardial inflammation, a hypercoagulable state, or direct myocardial suppression.

Pathological changes:

• In the level of cardiac tissue: minimal change to interstitial inflammatory infiltration and myocyte necrosis
• In the level of vasculature: micro-thrombosis and vascular inflammation

ST-Elevation MI (STEMI)

A US model from 9 major centers showed a 38% drop in total STEMI activations during the COVID-19 pandemic. There is a 40% reduction noted in Spain as well. there was also a delay between the first presentation to a medical encounter up to 318 min. This is important since COVID-19 can potentially be a cause of STEMI through microthrombi, cytokine storm, coronary spasm, or direct endothelial injury.

• Potential etiologies for the reduction in STEMI PPCI activations:
  • avoidance of medical care due to social distancing or concerns of contracting COVID-19 in the hospital
  • STEMI misdiagnosis
  • increased use of pharmacological reperfusion due to COVID-19

It is very important to realize if patients' anxiety is the reason behind decreasing the presentation of STEMI to U.S. hospitals.

• Treatment of STEMI & COVID-19: The specific protocols for the treatment have been evolving. Early recommendations showed intravenous thrombolysis as first-line therapy for STEMI patients with confirmed COVID-19 since most hospitals do not have protected cardiac catheterization labs.

Signs and Symptoms

The signs and symptoms of acute coronary syndrome include:

• Chest pain

• Substernal chest pain
• Occurs at rest or exertion
• Radiation to neck, jaw, left shoulder and left arm
• Aggravated by physical activity and emotional stress
• Relieved by rest, nitroglycerin or both

• Chest discomfort described crushing, squeezing, burning, choking, tightness or aching
• Dyspnea
• Diaphoresis
• Nausea and vomiting
• Fatigue
• Syncope

Treatment

In patients with ACS, and COVID-19 treatment should follow the guideline of the updated Society for Cardiovascular Angiography and Interventions guidelines.

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [2]; Associate Editor(s)-in-Chief:

Synonyms and keywords: Novel coronavirus, covid-19, COVID-19, SARS-CoV-2, Wuhan coronavirus

Overview

• COVID-19 patients with cardiovascular comorbidities have higher mortality.
• Hospitalized patients with COVID-19 and Cardiovascular disease seem to be more prevalent in both the USA and China.
• In a case series with 187 patients who had confirmed COVID-19, 27.8% of patients had a myocardial injury, which caused cardiac dysfunction and arrhythmias. The result was significantly higher mortality among patients with myocardial injury.
• It seems to be advisable to triage patients with COVID-19 based on their underlying CVD for a more aggressive treatment plan.
• The mortality during hospitalization was shown to be 7.62% for patients without underlying CVD and normal TnT levels, 13.33% for those with underlying CVD and normal TnT levels, 37.50% for those without underlying CVD but elevated TnT levels, and 69.44% for those with underlying CVD and elevated TnTs.

Classification

ST-Elevation Myocardial Infarction (STEMI)

A US model from 9 major centers showed a 38% drop in total STEMI activations during the COVID-19 pandemic. There is a 40% reduction noted in Spain as well. there was also a delay between the first presentation to a medical encounter up to 318 min. This is important since COVID-19 can potentially be a cause of STEMI through microthrombi, cytokine storm, coronary spasm, or direct endothelial injury.

• Potential etiologies for the reduction in STEMI PPCI activations:
  • avoidance of medical care due to social distancing or concerns of contracting COVID-19 in the hospital
  • STEMI misdiagnosis
  • increased use of pharmacological reperfusion due to COVID-19

It is very important to realize if patients' anxiety is the reason behind decreasing the presentation of STEMI to U.S. hospitals.

• Treatment of STEMI & COVID-19: The specific protocols for the treatment have been evolving. Early recommendations showed intravenous thrombolysis as first-line therapy for STEMI patients with confirmed COVID-19 since most hospitals do not have protected cardiac catheterization labs.

Pathophysiology

The mechanism of COVID-19 cardiovascular injury has not been fully understood and is likely multifactorial.

• SARS-CoV-2 virus attaches to ACE 2 protein for ligand binding before entering the cell via receptor-mediated endocytosis.
  • Based on single-cell RNA sequencing more than 7.5% of myocardial cells have positive ACE2 expression. This protein can mediate the entry of SARS-CoV-2 and result in direct cardiotoxicity.
• The cytokine release caused by the virus may lead to vascular inflammation, plaque instability, myocardial inflammation, a hypercoagulable state, or direct myocardial suppression.

Pathological changes:

• In the level of cardiac tissue: minimal change to interstitial inflammatory infiltration and myocyte necrosis
• In the level of vasculature: micro-thrombosis and vascular inflammation

Diagnosis

Diagnostic study of choice | History and Symptoms | Physical Examination | Laboratory Findings | Electrocardiogram | X-Ray Findings | Echocardiography and Ultrasound | CT-Scan Findings | MRI Findings | Other Imaging Findings | Other Diagnostic Studies

History and Symptoms

The signs and symptoms of acute coronary syndrome include:

• Chest pain

• Substernal chest pain
• Occurs at rest or exertion
• Radiation to neck, jaw, left shoulder and left arm
• Aggravated by physical activity and emotional stress
• Relieved by rest, nitroglycerin or both

• Chest discomfort described crushing, squeezing, burning, choking, tightness or aching
• Dyspnea
• Diaphoresis
• Nausea and vomiting
• Fatigue
• Syncope

Treatment

Medical Therapy | Interventions | Surgery | Primary Prevention | Secondary Prevention | Cost-Effectiveness of Therapy | Future or Investigational Therapies In patients with ACS, and COVID-19, treatment should follow the guidelines of the updated Society for Cardiovascular Angiography and Interventions.

History and Symptoms

• Chest pain

• Substernal chest pain
• Occurs at rest or exertion
• Radiation to neck, jaw, left shoulder and left arm
• Aggravated by physical activity and emotional stress
• Relieved by rest, nitroglycerin or both

• Chest discomfort described crushing, squeezing, burning, choking, tightness or aching
• Dyspnea
• Diaphoresis
• Nausea and vomiting
• Fatigue
• Syncope

Physical Examination

Patients with [disease name] usually appear [general appearance]. Physical examination of patients with [disease name] is usually remarkable for [finding 1], [finding 2], and [finding 3].

Treatment

In patients with ACS, and COVID-19, treatment should follow the guidelines of the updated Society for Cardiovascular Angiography and Interventions.