Sandbox:Mitra

Common Precipitating factors in COVID-19 patients

Cardiac

Myocardial ischemia

Arrhythmias (tachy- or brady Arrhythmias)

Stress-induced cardiomyopathy

Myocardial injury

Myocarditis

Pressure overload

Hypertensive urgency or emergency

Volume overload

Decreased compliance with diuretics

Renal dysfunction

Pulmonary

Acute Pulmonary embolism

Hypoxia

Pneumonia

ARDS

Increased systemic metabolic demand

Fever

Sepsis

Iatrogenic

Cardiovascular toxicity of medications

Aggressive fluid resuscitation

Others

Anemia

Decreased compliance with heart failure medications Acute Myocardial Injury Thank you for your great work! There are only a few comments which may help you to improve the page. Your name does not redirect to your “user page”. You may fix this. Create redirects to the page (including all the synonyms). Follow abc format throughout the page. For example, complete age, gender, race in “epidemiology and demographics”. Also, complete physical examination, x-ray, CT, MRI, … sections. If you have no data to put there, link the readers to corresponding pages, the same that you have done for treatment. There are several blank paragraphs on your page, please do the same for all of them. Include “Differentiating ((Page name)) from other Diseases” and make a table for differential diagnosis. Please be careful to paraphrase sentences that you use from other sources to avoid plagiarism. Some sentences are exactly the same as in “UpToDate”. Please change them. You may add a figure to your page, in particular for the pathophysiology section. Also, Make a table for differential diagnosis. Myocarditis and pericarditis (2 pages) Thank you for your great work! There are only a few comments which may help you to improve the page. In myocarditis page, I think some of the redirects and links should be to the COVID-related pages rather than general pages. For example, in differential diagnosis, linking to COVID-associated acute coronary syndrome or heart failure is more logical rather than ACS or heart failure. But for pericarditis page, you've used links greatly. Follow abc format throughout the page. You have most parts of the template but still, some are missing, like primary prevention and secondary prevention. In historical perspective, present data for COVID-associated myocarditis or pericarditis, not the COVID-19 itself. In myocarditis page, you may begin with that famous Italian case report presenting the first case of COVID-19 myocarditis (doi:10.1001/jamacardio.2020.1096). In overview sections of both pages, also use COVID-19-associated myocarditis or pericarditis, rather than COVID-19 itself. Please make a table for differential diagnosis. Create redirects to the page (including all the synonyms). Acute coronary syndrome Thank you for your great work! There are only a few comments which may help you to improve the page. Please reconsider the “Classification” section. I think it is not relevant to talk about the reduction in the incidence of MI during the COVID-19 outbreak, rather we should talk about the occurrence of COVID-associated acute coronary syndrome. Although these data are also given in ACS section of “UptoDate” but our wikidoc approach (according to the template) and personal preferences of Dr. Gibson are different, so it makes this section less relevant to our COVID-19 page. Pathophysiology also seems off-topic in most parts. For example in this sentence: The mechanism of COVID-19 cardiovascular injury has not been fully understood and is likely multifactorial” you are not going to talk about the myocardial injury in COVID-19. Please focus on ACS, not myocardial injury. You can use type I and II ischemia to extend the pathophysiology section. I think the “causes” section also needs revision. You’re giving data on classification; you can move this to the classification section. In addition, according to the universal definition of MI, we have 5 types of MI, even though I and II have been suggested for the pathophysiology of MI in COVID-19. Follow abc format throughout the page. All sections should be completed. Please make a table for differential diagnosis. Create redirects to the page (including all the synonyms). Response to the reviewer: Dear Mitra, thank you for your comments. I did editions in the mentioned sections according to Dr. Gibson, Sahar, and team's reviews. Some sections are newly added following the abc template Differential diagnosis section has already two links for the two types of MI which provide the related tables. Sahar also reviewed this part. More Redirects to related pages are added Arrhythmia Thank you for your great work! There are only a few comments which may help you to improve the page. Please delete unused sentences from the template. In pathophysiology, more data is given on pathophysiology of myocardial injury than arrhythmia in COVID-19 and makes the reader confused. For example Type 1 and type 2 pneumocytes exhibit ACE 2 receptors in the lung. Studies report that coronary endothelial cells in the heart and intrarenal endothelial cells and renal tubular epithelial cells in the kidney exhibit ACE2. ACE2 is an inverse regulator of the renin-angiotensin system. Or In COVID-19 patients, excessive ranges of circulating cytokines, especially interleukin (IL)-6 is related to in-hospital death.[9] etc. Prolong QT Interval, Atrial Arrhythmia, and Ventricular Arrhythmia are not considered symptoms. You may transfer them to the ECG section or other more related sections. Please make a table for differential diagnosis. Cardiogenic shock Thank you for your great work! There are only a few comments which may help you to improve the page. I think for historical perspective you can find more prior cases. The case you are mentioning was not actually the first case of cardiogenic shock in COVId-19, it was the first who showed viral particles in the myocardial biopsy. Please follow the abc format. You have so many missing sections. This page was a short page (with limited data) and most sections have overlap with other pages, but you may extend some parts and link different sections to corresponding pages. Nothing is written regarding the use of ECMO in COVID-19 patients. According to Dr. Gibson’s feedback, all pages should have a table for differential diagnosis. Create redirects to the page (including all the synonyms). Sudden cardiac death Thank you for your great work! There are only a few comments which may help you to improve the page. Please follow the abc format. You have so many missing sections. For example, for “Causes” you can add pulmonary embolism, MI, arrhythmias, etc. Dr. Gibson has also emphasized on adding “pulmonary embolism” as a cause of sudden cardiac death in COVID-19 patients. Most sentences on your page do not have appropriate citations. This page has overlap with other pages, mainly arrhythmia page, but you may extend some parts and link different sections to corresponding pages. Please try to link to COVID-19-related pages, rather than general pages, when possible. According to Dr. Gibson’s feedback, all pages should have a table for differential diagnosis. Create redirects to the page (including all the synonyms). Spontaneous coronary artery dissection Thank you for your great work! There are only a few comments which may help you to improve the page. This page is inherently a short page due to limited data, but please try to add more COVID-19 related data rather than general SCAD. You may use a few case reports of SCAD in COVID-19. Please follow the abc format. You have so many missing sections. For sections you have no data, use appropriate sentences from the template. The page has no reference. Create redirects to the page (including all the synonyms). Diseases Diagnostic tests Physical Examination Symptoms Past medical history Other Findings CT scan and MRI EKG Chest X-ray Tachypnea Tachycardia Fever Chest Pain Hemoptysis Dyspnea on Exertion Wheezing Chest Tenderness Nasalopharyngeal Ulceration Carotid Bruit Pulmonary embolism On CT angiography: Intra-luminal filling defect On MRI: Narrowing of involved vessel No contrast seen distal to obstruction Polo-mint sign (partial filling defect surrounded by contrast) S1Q3T3 pattern representing acute right heart strain Fleischner sign (enlarged pulmonary artery), Hampton hump, Westermark's sign ✔ ✔ ✔ (Low grade) ✔ ✔ (In case of massive PE) ✔ - - - - Hypercoagulating conditions (Factor V Leiden, thrombophilia, deep vein thrombosis, immobilization, malignancy, pregnancy) May be associated with metabolic alkalosis and syncope Congestive heart failure On CT scan: Mediastinal lymphadenopathy Hazy mediastinal fat On MRI: Abnormality of cardiac chambers (hypertrophy, dilation) Delayed enhancement MRI may help characterize the myocardial tissue (fibrosis) Late enhancement of contrast in conditions such as myocarditis, sarcoidosis, amyloidosis, Anderson-Fabry's disease, Chagas disease) Goldberg's criteria may aid in diagnosis of left ventricular dysfunction: (High specificity) SV1 or SV2 + RV5 or RV6 ≥3.5 mV Total QRS amplitude in each of the limb leads ≤0.8 mV R/S ratio <1 in lead V4 Cardiomegaly ✔ ✔ ✔ - - ✔ - - - - Previous myocardial infarction Hypertension (systemic and pulmonary) Cardiac arrythmias Viral infections (myocarditis) Congenital heart defects Right heart failure associated with: Hepatomegaly Positive hepato-jugular reflex Increased jugular venous pressure Peripheral edema Left heart failure associated with: Pulmonary edema Eventual right heart failure Percarditis On contrast enhanced CT scan: Enhancement of the pericardium (due to inflammation) Pericardial effusion Pericardial calcification On gadolinium-enhanced fat-saturated T1-weighted MRI: Pericardial enhancement (due to inflammation) Pericardial effusion ST elevation PR depression Large collection of fluid inside the pericardial sac (pericardial effusion) Calcification of pericardial sac ✔ ✔ ✔ (Low grade) ✔ (Relieved by sitting up and leaning forward) - ✔ - - - - Infections: Viral (Coxsackie virus, Herpes virus, Mumps virus, HIV) Bacteria (Mycobacterium tuberculosis-common in developing countries) Fungal (Histoplasmosis) Idiopathic in a large number of cases Autoimmune Uremia Malignancy Previous myocardial infarction May be clinically classified into: Acute (< 6 weeks) Sub-acute (6 weeks - 6 months) Chronic (> 6 months) Pneumonia On CT scan: (not generally indicated) Consolidation (alveolar/lobar pneumonia) Peribronchial nodules (bronchopneumonia) Ground-glass opacity (GGO) Abscess Pleural effusion On MRI: Not indicated Prolonged PR interval Transient T wave inversions Consolidation (alveolar/lobar pneumonia) Peribronchial nodules (bronchopneumonia) Ground-glass opacity (GGO) ✔ ✔ ✔ ✔ - ✔ ✔ - - - Ill-contact Travelling Smoking Diabetic Recent hospitalization Chronic obstructive pulmonary disease Requires sputum stain and culture for diagnosis Empiric management usually started before culture results Vasculitis On CT scan: (Takayasu arteritis) Vessel wall thickening Luminal narrowing of pulmonary artery Masses or nodules (ANCA-associated granulomatous vasculitis) On MRI: Homogeneous, circumferential vessel wall swelling Right or left bundle-branch block (Churg-Strauss syndrome) Atrial fibrillation (Churg-Strauss syndrome) Non-specific ST segment and T wave changes Nodules Cavitation ✔ ✔ ✔ ✔ ✔ ✔ - ✔ ✔ ✔ Takayasu arteritis usually found in persons aged 4-60 years with a mean of 30 Giant-cell arteritis usually occurrs in persons aged > 60 years Churg-Strauss syndrome may present with asthma, sinusitis, transient pulmonary infiltrates and neuropathy alongwith cardiac involvement Granulomatous vasculitides may present with nephritis and upper airway (nasopharyngeal) destruction Chronic obstructive pulmonary disease (COPD) On CT scan: Chronic bronchitis may show bronchial wall thickening, scarring with bronchovascular irregularity, fibrosis Emphysema may show alveolar septal destruction and airspace enlargement (Centrilobular- upper lobe, panlobular- lower lobe) Giant bubbles On MRI: Increased diameter of pulmonary arteries Peripheral pulmonary vasculature attentuation Loss of retrosternal airspace due to right ventricular enlargement Hyperpolarized Helium MRI may show progressively poor ventilation and destruction of lung Multifocal atrial tachycardia (atleast 3 distinct P wave morphologies) Enlarged lung shadows (emphysema) Flattening of diaphragm (emphysema) ✔ ✔ - - - ✔ ✔ - - - Smoking Alpha-1 antitrypsin deficiency Increased sputum production (chronic bronchitis) Cough Alpha 1 antitrypsin deficiency may be associated with hepatomegaly COVID-19-associated heart failure