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__NOTOC__
__NOTOC__
{{COVID-19-associated heart failure}}
{{COVID-19 associated Heart Failure}}
'''For patient information, click [[Xyz (patient information)|here]]'''
'''For patient information, click [[Xyz (patient information)|here]]'''


{{CMG}}; {{AE}}
{{CMG}}; {{AE}} {{Mitra}}


{{SK}}  
{{SK}}  


==[[Xyz overview|Overview]]==
==[[Heart Failure overview|Overview]]==


==[[Xyz historical perspective|Historical Perspective]]==
*Patients with chronic heart failure (HF) may be at higher risk of developing severe COVID-19 infection due to the advanced age and the presence of multiple comorbidities.
*Both de novo acute heart failure and acute decompensation of chronic heart failure can occur in patients with COVID-19.


==[[Xyz classification|Classification]]==
==[[Heart Failure historical perspective|Historical Perspective]]==


==[[Xyz pathophysiology|Pathophysiology]]==
==[[Heart Failure classification|Classification]]==


==[[Xyz causes|Causes]]==
==[[Heart Failure pathophysiology|Pathophysiology]]==


==[[Xyz differential diagnosis|Differentiating Xyz from other Diseases]]==
*Presumed pathophysiologic mechanisms for the development of new or worsening heart failure in patients with COVID-19 include:<ref name="pmid32219357">{{Cite pmid|32219357}}</ref> <ref name="pmid32360242">{{Cite pmid|32360242}}</ref> <ref name="pmid32186331">{{Cite pmid|32186331}}</ref> <ref name="pmid30625066">{{Cite pmid|30625066}}</ref> <ref name="pmid32140732">{{Cite pmid|32140732}}</ref>   
**Acute exacerbation of chronic heart failure
**Acute myocardial injury (which in turn can be caused by several mechanisms)
**Stress cardiomyopathy (i.e., Takotsubo cardiomyopathy)
**Impaired myocardial relaxation resulting in diastolic dysfunction [i.e., Heart failure with preserved ejection fraction (HFpEF)]
**Right-sided heart failure, secondary to pulmonary hypertension caused by hypoxia and acute respiratory distress syndrome (ARDS)


==[[Xyz epidemiology and demographics|Epidemiology and Demographics]]==
==[[Heart Failure causes|Causes]]==


==[[Xyz risk factors|Risk Factors]]==
==[[Heart Failure differential diagnosis|Differentiating Heart Failure from other Diseases]]==


==[[Xyz screening|Screening]]==
==[[Heart Failure epidemiology and demographics|Epidemiology and Demographics]]==
 
==[[Heart Failure risk factors|Risk Factors]]==
 
==[[Heart Failure screening|Screening]]==
 
==[[Heart Failure natural history, complications and prognosis|Natural History, Complications and Prognosis]]==


==[[Xyz natural history, complications and prognosis|Natural History, Complications and Prognosis]]==


==Diagnosis==
==Diagnosis==
[[Xyz diagnostic study of choice|Diagnostic study of choice]] | [[Xyz history and symptoms|History and Symptoms]] | [[Xyz physical examination|Physical Examination]] | [[Xyz laboratory findings|Laboratory Findings]] | [[Xyz electrocardiogram|Electrocardiogram]] | [[Xyz x ray|X-Ray Findings]] | [[Xyz echocardiography and ultrasound|Echocardiography and Ultrasound]] | [[Xyz CT scan|CT-Scan Findings]] | [[Xyz MRI|MRI Findings]] | [[Xyz other imaging findings|Other Imaging Findings]] | [[Xyz other diagnostic studies|Other Diagnostic Studies]]
[[COVID-19-associated heart failurediagnostic study of choice|Diagnostic study of choice]] | [[COVID-19-associated heart failure history and symptoms|History and Symptoms]] | [[Xyz physical examination|Physical Examination]] | [[Xyz laboratory findings|Laboratory Findings]] | [[Xyz electrocardiogram|Electrocardiogram]] | [[Xyz x ray|X-Ray Findings]] | [[Xyz echocardiography and ultrasound|Echocardiography and Ultrasound]] | [[Xyz CT scan|CT-Scan Findings]] | [[Xyz MRI|MRI Findings]] | [[Xyz other imaging findings|Other Imaging Findings]] | [[Xyz other diagnostic studies|Other Diagnostic Studies]]
 
 
 
| [[Xyz physical examination|Physical Examination]] | [[Heart Failure laboratory findings|Laboratory Findings]] | [[Heart Failure electrocardiogram|Electrocardiogram]]
 
====Electrocardiography (ECG)====
*There is no specific electrocardiographic sign for acute heart failure in COVID-19 patients.
*The ECG may help in identifying preexisting cardiac abnormalities and precipitating factors such as ischemia, myocarditis, and arrhythmias.
*These ECG findings may include:
**Low QRS Voltage
**Left ventricular hypertrophy
**Left atrial enlargement
**Left bundle branch block
**Poor R progression
**ST-T changes
| [[Xyz x ray|X-Ray Findings]]
====Chest x-ray (CXR)====
*The Chest x-ray may show evidence of:
**Cardiomegaly
**Pulmonary congestion
**Increased pulmonary vascular markings.
*Signs of pulmonary edema may be obscured by underlying respiratory involvement and ARDS due to COVID-19.
| [[Heart Failure echocardiography and ultrasound|Echocardiography and Ultrasound]]
 
====Echocardiography====
*A complete standard transthoracic (TTE) has not been recommended in COVID-19 patients considering the limited personal protective equipment (PPE) and the risk of exposure of additional health care personnel.<ref name="pmid32391912">{{Cite pmid|32391912}}</ref>
*To deal with limited resources (both personal protective equipment and personnel) and reducing the exposure time of personnel, a focused TTE to find gross abnormalities in cardiac structure/function seems satisfactory.
*In addition, bedside options, which may be performed by the trained personnel who might already be in the room with these patients, might also be considered. These include:
**Cardiac point-of-care ultrasound (POCUS)
**Focused cardiac ultrasound study (FoCUS)
**Critical care echocardiography
*Cardiac ultrasound can help in assessing the following parameters:
**Left ventricular systolic function (ejection fraction) to distinguish systolic dysfunction with a reduced ejection fraction (<40%) from diastolic dysfunction with a preserved ejection fraction.
**Left ventricular diastolic function
**Left ventricular structural abnormalities, including LV size and LV wall thickness
**Left atrial size
**Right ventricular size and function
**Detection and quantification of valvular abnormalities
**Measurement of systolic pulmonary artery pressure
**Detection and quantification of pericardial effusion
**Detection of regional wall motion abnormalities/reduced strain that would suggest an underlying ischemia
| [[Heart Failure CT scan|CT-Scan Findings]] | [[Heart Failure MRI|MRI Findings]] | [[Heart Failure other imaging findings|Other Imaging Findings]] | [[Heart Failure other diagnostic studies|Other Diagnostic Studies]]
====Cardiac biomarkers====
*Cardiac Troponins:
**Elevated cardiac troponin levels suggest the presence of myocardial cell injury or death.
**Cardiac troponin levels may increase in patients with chronic or acute decompensated HF.<ref name="pmid20863950">{{Cite pmid|20863950}}</ref>
*Natriuretic Peptides:
**Natriuretic peptides (BNP/NT-proBNP) are released from the heart in response to increased myocardial stress and are quantitative markers of increased intracardiac filling pressure.<ref name="pmid28062628">{{Cite pmid|28062628}}</ref>
**Elevated BNP and NT-proBNP are of both diagnostic and prognostic significance in patients with heart failure.
**Increased BNP or NT-proBNP levels have been demonstrated in COVID-19 patients.
**Increased NT-proBNP level was associated with worse clinical outcomes in patients with severe COVID-19.<ref name="pmid32293449">{{Cite pmid|32293449}}</ref> <ref name="pmid32232979">{{Cite pmid|32232979}}</ref>
**However, increased natriuretic peptide levels are frequently seen among patients with severe inflammatory or respiratory diseases.<ref name="pmid18298480">{{Cite pmid|18298480}}</ref> <ref name="pmid16442916">{{Cite pmid|16442916}}</ref> <ref name="pmid28322314">{{Cite pmid|28322314}}</ref> <ref name="pmid23837838">{{Cite pmid|23837838}}</ref> <ref name="pmid21478812">{{Cite pmid|21478812}}</ref>
**Therefore, routine measurement of BNP/NT-proBNP has not been recommended in COVID-19 patients, unless there is a high suspicion of HF based on clinical grounds.


==Treatment==
==Treatment==
[[Xyz medical therapy|Medical Therapy]] | [[Xyz interventions|Interventions]] | [[Xyz surgery|Surgery]] | [[Xyz primary prevention|Primary Prevention]] | [[Xyz secondary prevention|Secondary Prevention]] | [[Xyz cost-effectiveness of therapy|Cost-Effectiveness of Therapy]] | [[Xyz future or investigational therapies|Future or Investigational Therapies]]
[[Heart Failure medical therapy|Medical Therapy]]  
 
*Patients with chronic heart failure are recommended to continue their previous guideline-directed medical therapy, including beta-blockers, ACEI or ARB, and mineralocorticoid receptor antagonists. <ref name="pmid31129923">{{Cite pmid|31129923}}</ref>
*Acute heart failure in the setting of COVID-19 is generally treated similarly to acute heart failure in other settings. These may include:
**Fluid restriction
**Diuretic therapy
**Vasopressors and/or inotropes
**Ventricular assisted devices and extracorporeal membrane oxygenation (ECMO)
*Beta-blockers should not be initiated during the acute stage due to their negative inotropic effects.<ref name="pmid24251454">{{Cite pmid|24251454}}</ref>
*Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) should be used with caution in patients with acute heart failure due to their effect on fluid and sodium retention.<ref name="pmid12656651">{{Cite pmid|12656651}}</ref>
 
| [[Heart Failure interventions|Interventions]] | [[Heart Failure surgery|Surgery]] | [[Heart Failure primary prevention|Primary Prevention]] | [[Heart Failure secondary prevention|Secondary Prevention]] | [[Heart Failure cost-effectiveness of therapy|Cost-Effectiveness of Therapy]] | [[Xyz future or investigational therapies|Future or Investigational Therapies]]


==Case Studies==
==Case Studies==

Revision as of 11:56, 25 June 2020

Template:COVID-19 associated Heart Failure For patient information, click here

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Mitra Chitsazan, M.D.[2]

Synonyms and keywords:

Overview

  • Patients with chronic heart failure (HF) may be at higher risk of developing severe COVID-19 infection due to the advanced age and the presence of multiple comorbidities.
  • Both de novo acute heart failure and acute decompensation of chronic heart failure can occur in patients with COVID-19.

Historical Perspective

Classification

Pathophysiology

  • Presumed pathophysiologic mechanisms for the development of new or worsening heart failure in patients with COVID-19 include:[1] [2] [3] [4] [5]
    • Acute exacerbation of chronic heart failure
    • Acute myocardial injury (which in turn can be caused by several mechanisms)
    • Stress cardiomyopathy (i.e., Takotsubo cardiomyopathy)
    • Impaired myocardial relaxation resulting in diastolic dysfunction [i.e., Heart failure with preserved ejection fraction (HFpEF)]
    • Right-sided heart failure, secondary to pulmonary hypertension caused by hypoxia and acute respiratory distress syndrome (ARDS)

Causes

Differentiating Heart Failure from other Diseases

Epidemiology and Demographics

Risk Factors

Screening

Natural History, Complications and Prognosis

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


| Physical Examination | Laboratory Findings | Electrocardiogram

Electrocardiography (ECG)

  • There is no specific electrocardiographic sign for acute heart failure in COVID-19 patients.
  • The ECG may help in identifying preexisting cardiac abnormalities and precipitating factors such as ischemia, myocarditis, and arrhythmias.
  • These ECG findings may include:
    • Low QRS Voltage
    • Left ventricular hypertrophy
    • Left atrial enlargement
    • Left bundle branch block
    • Poor R progression
    • ST-T changes

| X-Ray Findings

Chest x-ray (CXR)

  • The Chest x-ray may show evidence of:
    • Cardiomegaly
    • Pulmonary congestion
    • Increased pulmonary vascular markings.
  • Signs of pulmonary edema may be obscured by underlying respiratory involvement and ARDS due to COVID-19.

| Echocardiography and Ultrasound

Echocardiography

  • A complete standard transthoracic (TTE) has not been recommended in COVID-19 patients considering the limited personal protective equipment (PPE) and the risk of exposure of additional health care personnel.[6]
  • To deal with limited resources (both personal protective equipment and personnel) and reducing the exposure time of personnel, a focused TTE to find gross abnormalities in cardiac structure/function seems satisfactory.
  • In addition, bedside options, which may be performed by the trained personnel who might already be in the room with these patients, might also be considered. These include:
    • Cardiac point-of-care ultrasound (POCUS)
    • Focused cardiac ultrasound study (FoCUS)
    • Critical care echocardiography
  • Cardiac ultrasound can help in assessing the following parameters:
    • Left ventricular systolic function (ejection fraction) to distinguish systolic dysfunction with a reduced ejection fraction (<40%) from diastolic dysfunction with a preserved ejection fraction.
    • Left ventricular diastolic function
    • Left ventricular structural abnormalities, including LV size and LV wall thickness
    • Left atrial size
    • Right ventricular size and function
    • Detection and quantification of valvular abnormalities
    • Measurement of systolic pulmonary artery pressure
    • Detection and quantification of pericardial effusion
    • Detection of regional wall motion abnormalities/reduced strain that would suggest an underlying ischemia

| CT-Scan Findings | MRI Findings | Other Imaging Findings | Other Diagnostic Studies

Cardiac biomarkers

  • Cardiac Troponins:
    • Elevated cardiac troponin levels suggest the presence of myocardial cell injury or death.
    • Cardiac troponin levels may increase in patients with chronic or acute decompensated HF.[7]
  • Natriuretic Peptides:
    • Natriuretic peptides (BNP/NT-proBNP) are released from the heart in response to increased myocardial stress and are quantitative markers of increased intracardiac filling pressure.[8]
    • Elevated BNP and NT-proBNP are of both diagnostic and prognostic significance in patients with heart failure.
    • Increased BNP or NT-proBNP levels have been demonstrated in COVID-19 patients.
    • Increased NT-proBNP level was associated with worse clinical outcomes in patients with severe COVID-19.[9] [10]
    • However, increased natriuretic peptide levels are frequently seen among patients with severe inflammatory or respiratory diseases.[11] [12] [13] [14] [15]
    • Therefore, routine measurement of BNP/NT-proBNP has not been recommended in COVID-19 patients, unless there is a high suspicion of HF based on clinical grounds.

Treatment

Medical Therapy

  • Patients with chronic heart failure are recommended to continue their previous guideline-directed medical therapy, including beta-blockers, ACEI or ARB, and mineralocorticoid receptor antagonists. [16]
  • Acute heart failure in the setting of COVID-19 is generally treated similarly to acute heart failure in other settings. These may include:
    • Fluid restriction
    • Diuretic therapy
    • Vasopressors and/or inotropes
    • Ventricular assisted devices and extracorporeal membrane oxygenation (ECMO)
  • Beta-blockers should not be initiated during the acute stage due to their negative inotropic effects.[17]
  • Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) should be used with caution in patients with acute heart failure due to their effect on fluid and sodium retention.[18]

| Interventions | Surgery | Primary Prevention | Secondary Prevention | Cost-Effectiveness of Therapy | Future or Investigational Therapies

Case Studies

Case #1

  1. ↑ PMID 32219357 (PMID 32219357)
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  2. ↑ PMID 32360242 (PMID 32360242)
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  3. ↑ PMID 32186331 (PMID 32186331)
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  4. ↑ PMID 30625066 (PMID 30625066)
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  5. ↑ PMID 32140732 (PMID 32140732)
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  6. ↑ PMID 32391912 (PMID 32391912)
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  7. ↑ PMID 20863950 (PMID 20863950)
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  8. ↑ PMID 28062628 (PMID 28062628)
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  9. ↑ PMID 32293449 (PMID 32293449)
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  10. ↑ PMID 32232979 (PMID 32232979)
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  11. ↑ PMID 18298480 (PMID 18298480)
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  12. ↑ PMID 16442916 (PMID 16442916)
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  13. ↑ PMID 28322314 (PMID 28322314)
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  14. ↑ PMID 23837838 (PMID 23837838)
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  15. ↑ PMID 21478812 (PMID 21478812)
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  16. ↑ PMID 31129923 (PMID 31129923)
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  17. ↑ PMID 24251454 (PMID 24251454)
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  18. ↑ PMID 12656651 (PMID 12656651)
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