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# Sara Haddadi MD, Miami FL | # Sara Haddadi MD, Miami FL | ||
==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 [[Cardiovascular disease|CVD]] but elevated TnT levels | |||
**69.44% for those with underlying CVD and elevated TnTs.<ref name="pmid32219356">{{cite journal| author=Guo T, Fan Y, Chen M, Wu X, Zhang L, He T | display-authors=etal| title=Cardiovascular Implications of Fatal Outcomes of Patients With Coronavirus Disease 2019 (COVID-19). | journal=JAMA Cardiol | year= 2020 | volume= | issue= | pages= | pmid=32219356 | doi=10.1001/jamacardio.2020.1017 | pmc=7101506 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32219356 }} </ref> | |||
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Revision as of 14:26, 14 July 2020
- Sara Haddadi MD, Miami FL
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:
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| 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 | _ |
References |
- ↑ Guo T, Fan Y, Chen M, Wu X, Zhang L, He T; et al. (2020). "Cardiovascular Implications of Fatal Outcomes of Patients With Coronavirus Disease 2019 (COVID-19)". JAMA Cardiol. doi:10.1001/jamacardio.2020.1017. PMC 7101506 Check
|pmc=value (help). PMID 32219356 Check|pmid=value (help).
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[1]
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.[2]
- 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.[3]
- 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.[2]
Signs and Symptoms
The signs and symptoms of acute coronary syndrome include:[4]
- 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.[5]
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Xyz Microchapters |
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Diagnosis |
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Treatment |
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Case Studies |
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Sandbox:Sara Haddadi On the Web |
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American Roentgen Ray Society Images of Sandbox:Sara Haddadi |
For patient information, click here
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. [1]
- 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.[6]
Historical Perspective
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.[2]
- 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.[3]
- 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.[2]
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[1]
Causes
Differentiating Xyz 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
History and Symptoms
The signs and symptoms of acute coronary syndrome include:[4]
- 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.[1] [5]
Case Studies
Risk Factors
There are no established risk factors for [disease name].
OR
The most potent risk factor in the development of [disease name] is [risk factor 1]. Other risk factors include [risk factor 2], [risk factor 3], and [risk factor 4].
OR
Common risk factors in the development of [disease name] include [risk factor 1], [risk factor 2], [risk factor 3], and [risk factor 4].
OR
Common risk factors in the development of [disease name] may be occupational, environmental, genetic, and viral.
Screening
There is insufficient evidence to recommend routine screening for [disease/malignancy].
OR
According to the [guideline name], screening for [disease name] is not recommended.
OR
According to the [guideline name], screening for [disease name] by [test 1] is recommended every [duration] among patients with [condition 1], [condition 2], and [condition 3].
Natural History, Complications, and Prognosis
If left untreated, [#]% of patients with [disease name] may progress to develop [manifestation 1], [manifestation 2], and [manifestation 3].
OR
Common complications of [disease name] include [complication 1], [complication 2], and [complication 3].
OR
Prognosis is generally excellent/good/poor, and the 1/5/10-year mortality/survival rate of patients with [disease name] is approximately [#]%.
Diagnosis
Diagnostic Study of Choice
The diagnosis of [disease name] is made when at least [number] of the following [number] diagnostic criteria are met: [criterion 1], [criterion 2], [criterion 3], and [criterion 4].
OR
The diagnosis of [disease name] is based on the [criteria name] criteria, which include [criterion 1], [criterion 2], and [criterion 3].
OR
The diagnosis of [disease name] is based on the [definition name] definition, which includes [criterion 1], [criterion 2], and [criterion 3].
OR
There are no established criteria for the diagnosis of [disease name].
History and Symptoms
- 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[4]
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].
OR
Common physical examination findings of [disease name] include [finding 1], [finding 2], and [finding 3].
OR
The presence of [finding(s)] on physical examination is diagnostic of [disease name].
OR
The presence of [finding(s)] on physical examination is highly suggestive of [disease name].
Laboratory Findings
An elevated/reduced concentration of serum/blood/urinary/CSF/other [lab test] is diagnostic of [disease name].
OR
Laboratory findings consistent with the diagnosis of [disease name] include [abnormal test 1], [abnormal test 2], and [abnormal test 3].
OR
[Test] is usually normal among patients with [disease name].
OR
Some patients with [disease name] may have elevated/reduced concentration of [test], which is usually suggestive of [progression/complication].
OR
There are no diagnostic laboratory findings associated with [disease name].
Electrocardiogram
There are no ECG findings associated with [disease name].
OR
An ECG may be helpful in the diagnosis of [disease name]. Findings on an ECG suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].
X-ray
There are no x-ray findings associated with [disease name].
OR
An x-ray may be helpful in the diagnosis of [disease name]. Findings on an x-ray suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].
OR
There are no x-ray findings associated with [disease name]. However, an x-ray may be helpful in the diagnosis of complications of [disease name], which include [complication 1], [complication 2], and [complication 3].
Echocardiography or Ultrasound
There are no echocardiography/ultrasound findings associated with [disease name].
OR
Echocardiography/ultrasound may be helpful in the diagnosis of [disease name]. Findings on an echocardiography/ultrasound suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].
OR
There are no echocardiography/ultrasound findings associated with [disease name]. However, an echocardiography/ultrasound may be helpful in the diagnosis of complications of [disease name], which include [complication 1], [complication 2], and [complication 3].
CT scan
There are no CT scan findings associated with [disease name].
OR
[Location] CT scan may be helpful in the diagnosis of [disease name]. Findings on CT scan suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].
OR
There are no CT scan findings associated with [disease name]. However, a CT scan may be helpful in the diagnosis of complications of [disease name], which include [complication 1], [complication 2], and [complication 3].
MRI
There are no MRI findings associated with [disease name].
OR
[Location] MRI may be helpful in the diagnosis of [disease name]. Findings on MRI suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].
OR
There are no MRI findings associated with [disease name]. However, a MRI may be helpful in the diagnosis of complications of [disease name], which include [complication 1], [complication 2], and [complication 3].
Other Imaging Findings
There are no other imaging findings associated with [disease name].
OR
[Imaging modality] may be helpful in the diagnosis of [disease name]. Findings on an [imaging modality] suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].
Other Diagnostic Studies
There are no other diagnostic studies associated with [disease name].
OR
[Diagnostic study] may be helpful in the diagnosis of [disease name]. Findings suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].
OR
Other diagnostic studies for [disease name] include [diagnostic study 1], which demonstrates [finding 1], [finding 2], and [finding 3], and [diagnostic study 2], which demonstrates [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.[1] [5]
- ↑ 1.0 1.1 1.2 1.3 1.4 Kang Y, Chen T, Mui D, Ferrari V, Jagasia D, Scherrer-Crosbie M; et al. (2020). "Cardiovascular manifestations and treatment considerations in covid-19". Heart. doi:10.1136/heartjnl-2020-317056. PMC 7211105 Check
|pmc=value (help). PMID 32354800 Check|pmid=value (help). - ↑ 2.0 2.1 2.2 2.3 Ullah W, Sattar Y, Saeed R, Ahmad A, Boigon MI, Haas DC; et al. (2020). "As the COVID-19 pandemic drags on, where have all the STEMIs gone?". Int J Cardiol Heart Vasc. 29: 100550. doi:10.1016/j.ijcha.2020.100550. PMC 7261452 Check
|pmc=value (help). PMID 32550258 Check|pmid=value (help). - ↑ 3.0 3.1 Garcia S, Albaghdadi MS, Meraj PM, Schmidt C, Garberich R, Jaffer FA; et al. (2020). "Reduction in ST-Segment Elevation Cardiac Catheterization Laboratory Activations in the United States During COVID-19 Pandemic". J Am Coll Cardiol. 75 (22): 2871–2872. doi:10.1016/j.jacc.2020.04.011. PMC 7151384 Check
|pmc=value (help). PMID 32283124 Check|pmid=value (help). - ↑ 4.0 4.1 4.2 Abidov A, Rozanski A, Hachamovitch R, Hayes SW, Aboul-Enein F, Cohen I; et al. (2005). "Prognostic significance of dyspnea in patients referred for cardiac stress testing". N Engl J Med. 353 (18): 1889–98. doi:10.1056/NEJMoa042741. PMID 16267320. Review in: Evid Based Med. 2006 Jun;11(3):91
- ↑ 5.0 5.1 5.2 Szerlip M, Anwaruddin S, Aronow HD, Cohen MG, Daniels MJ, Dehghani P; et al. (2020). "Considerations for cardiac catheterization laboratory procedures during the COVID-19 pandemic perspectives from the Society for Cardiovascular Angiography and Interventions Emerging Leader Mentorship (SCAI ELM) Members and Graduates". Catheter Cardiovasc Interv. doi:10.1002/ccd.28887. PMID 32212409 Check
|pmid=value (help). - ↑ Guo T, Fan Y, Chen M, Wu X, Zhang L, He T; et al. (2020). "Cardiovascular Implications of Fatal Outcomes of Patients With Coronavirus Disease 2019 (COVID-19)". JAMA Cardiol. doi:10.1001/jamacardio.2020.1017. PMC 7101506 Check
|pmc=value (help). PMID 32219356 Check|pmid=value (help).