COVID-19-associated cardiogenic shock
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: : Alieh Behjat, M.D.[2]
Synonyms and keywords:: Novel coronavirus, COVID-19, Wuhan coronavirus, coronavirus disease-19, coronavirus disease 2019, SARS-CoV-2, COVID-19, 2019-nCoV, 2019 novel coronavirus, cardiovascular finding in COVID-19, cardiogenic shock, COVID-19 associated cardiogenic shock
Overview
The first confirmed instance of cardiogenic shock due to COVID-19 infection through myocardial infiltration by viral particles was in a 69-year-old patient from Italy. This was confirmed via biopsy. Since then, the two most probable mechanisms of cardiogenic shock related to COVID-19 are direct invasion and cytokine storm. According to a recent study out of an ICU in Washington state, one-third of critically ill patients with COVID-19 had clinical signs of cardiogenic shock and cardiomyopathy. According to another observational study in China, COVID-19 associated cardiogenic shock has a poor prognosis.
Historical Perspective
- The novel coronavirus, SARS-CoV-2, is identified as the cause of an outbreak of respiratory illness first detected in Wuhan, China in late December 2019. It was named SARS-CoV-2 for its similarity severe acute respiratory syndrome related coronaviruses such as SARS-CoV, which caused acute respiratory distress syndrome (ARDS) in 2002–2003. [1][2]
- On March 12, 2020, the WHO declared the Coronavirus disease 2019 (COVID-19) outbreak to be a pandemic.[3]
- The first confirmed instance of cardiogenic shock due to COVID-19 infection through myocardial infection by viral particles was in a 69-year-old patient from Italy. This was confirmed via biopsy. [4]
To view the historical perspective of COVID-19, click here.
Classification
- There is no specific classification for COVID-19 associated cardiogenic shock. To view cardiogenic shock classification, click here.
Pathophysiology
The two most likely mechanisms that contribute to COVID-19 cardiogenic shock are: [5] [6]
- Direct invasion of the virus into the cardiomyocytes
- Cytokine storm activated by T helper cells (Th1 and Th2) that triggers a systemic hyperinflammatory response
Causes
The causes of cardiogenic shock related to COVID-19 may include: [7] [8]
- Newly emerging COVID-19 associated myocarditis, cardiac arrhythmias, cardiomyopathy, or an acute coronary syndrome deteriorated into cardiogenic shock
- Worsening of previous left ventricular failure due to COVID-19
- COVID-19-associated multisystem inflammatory syndromein children (MIS-C)
Differentiating COVID-19 associated cardiogenic shock from other Diseases
Cardiogenic shock related to COVID-19 must be differentiated from other diseases which include: [9] [10]
- Distributive shock
- Hypovolemic shock
- Mixed (distributive and cardiogenic shock).
Some hemodynamic parameters would help differentiate significant types of shock: [11]
| Cardiac Output | Pulmonary Capillary Wedge Pressure | Systemic Vascular Resistance | Pulmonary artery diastolic pressure | SVO2 | |
|---|---|---|---|---|---|
| COVID-19-associated cardiogenic shock | ↓ | ↑↔ | ↑ | ↑ | ↓ |
| Septic shock | ↑ | ↓ | ↓ | ↓ | ↓ |
| Hypovolemic shock | ↓ | ↓ | ↑ | ↓ | ↑ |
Epidemiology and Demographics
- According to a recent study out of an ICU in Washington state, one-third of critically ill patients with COVID-19 had clinical signs of cardiogenic shock and cardiomyopathy.[12] There are few anecdotal reports of cardiogenic shock related to COVID-19. [4] [13]
Age
- There is no data on age predilection to cardiogenic shock in COVID-19.
Gender
- There is no data on gender predilection to cardiogenic shock in COVID-19.
Race
- There is no data on racial predilection to cardiogenic shock in COVID-19.
Risk Factors
- There are no established risk factors for COVID-19-associated cardiogenic shock.
- To view risk factors for the severe form of COVID-19 disease, click here.
- Moreover, in order to read more on the risk factors of cardiogenic shock, generally, click here.
Screening
- There is insufficient evidence to recommend routine screening for COVID-19-associated cardiogenic shock.
Natural History, Complications and Prognosis
- According to an observational study in China, COVID-19 associated cardiogenic shock has a poor prognosis.
- In spite of using Extracorporeal membrane oxygenation (ECMO), 83% of patients died. [14] [15]
Diagnosis
Diagnostic Study of Choice
- A diagnosis of cardiogenic shock related to COVID-19 can be made when Systolic Blood Pressure is lower than 90 mmHg for more than 15 minutes with impaired organ perfusion while Urine output is less than 30 m/hr in a patient with COVID-19 disease.[15]
To view cardiogenic shock diagnostic criteria, click here.
History and Symptoms:
- According to anecdotal reports, some patients that have presented with COVID-19 related cardiogenic shock did not have any cardiovascular risk factors.
- A 69-year-old patient from Italy has been reported by Tavazzi et al., as a COVID-19-associated cardiogenic shock case.
- This patient had flu-like symptoms when hospitalized and quickly deteriorated into respiratory distress and cardiogenic shock. [4]
- Four patients with cardiogenic shock complication related to COVID-19 were reported by Sanchez-Recalde, et al.
- These patients were hospitalized between March 1, 2020 and April 15, 2020 and included:[13]
- A 42-year-old woman, who had dyslipidemia as a cardiovascular risk factor
- A 50-year-old man, without any cardiovascular risk factors, admitted with severe bilateral pneumonia related to COVID-19. After a few hours, he developed cardiogenic shock
- A 75-year-old man who did not have any cardiovascular risk factors and was admitted due to dyspnea, chest pain, and bilateral COVID-19 pneumonia
- A 37-year-old woman, with a history of obesity and deep venous thrombosis, and had symptoms of dyspnea and chest pain
- These patients were hospitalized between March 1, 2020 and April 15, 2020 and included:[13]
Physical Examination
Physical examination findings that may be of note for the diagnosis of Covid-19 associated cardiogenic shock include:[16]
- Assessment of consciousness level
- Extremities, whether they are warm or cool, is helpful for evaluation of cardiogenic shock
- Vital signs (tachycardia and hypotension and tachypnea)
- Evaluation of volume status: CVP (increased JVP), edema
- Skin pallor
Laboratory Findings
- In COVID-19 patients, it is essential to differentiate the type of shock. Two tests are best able to clarify this, and result in higher levels in patients with cardiogenic shock related to COVID-19. These tests are: [17]
- serum brain natriuretic peptide (BNP)
- Troponin
- In addition, the increase of some biomarkers demonstrates poor prognosis, increased mortality, and more severe symptoms in COVID-19 patients:[18]
Electrocardiogram
- There is no specific electrocardiographic finding for cardiogenic shock in COVID-19 patients.
- The ECG can help to find previous cardiac abnormalities and triggering factors, such as acute myocardial infarction, and arrhythmias, which could lead to cardiogenic shock [19]
X-ray
- In a patient with COVID-19-associated cardiogenic shock, CXR could manifest coexisting acute respiratory illness and also cardiogenic pulmonary edema. Some findings, such as cardiomegaly and increased vascular markings, can suggest preexisting heart failure. [20]
Echocardiography or Ultrasound
- Echocardiography is an appropriate way to identify the extent of cardiac involvement in COVID-19-associated cardiogenic shock cases.[17]
CT scan
- Generally, aCT scan is not suggested as a primary imaging study for evaluating a case of cardiogenic shock related to COVID-19. However, it can useful for observing coexisting ARDS by demonstrating a ground-glass opacity.[20]
To view the CT scan findings on COVID-19, click here.
MRI
- Generally, in patients with COVID-19-associated cardiogenic shock, Cardiac MRI for the assessment of preexisting disorders such as myocarditis should not be done.[21]
To view the MRI findings on COVID-19, click here.
Other Imaging Findings
- To view other imaging findings on COVID-19, click here.
Other Diagnostic Studies
- To view other diagnostic studies for COVID-19, click here.
Treatment
Cardiogenic shock medical therapy:
- Fluid resuscitation (crystalloid IV fluids are more efficient than colloid solutions)
- Administration of vasopressors and inotropes to stabilize shock
- Assess other types of shock and mixed etiologies of shock if hemodynamics not refining, specifically in patients with a previous cardiac abnormality [21]
Mechanical Support:
- In treating patients with cardiogenic shock related to COVID-19, the efficacy of extracorporeal membrane oxygenation (ECMO) is indistinct, however it may be used in the most critically ill and highly selective patients.
- Although specialists implicate ECMO and mechanical circulatory support devices in severe cased of COVID-19 related cardiogenic shock, the mortality rate if high in those patients who undergo this treatment.
- It has been reported in a case series from China, that most of these patients had a poor prognosis and did not survive despite implicating ECMO. [22] [14]
Surgery
- Surgical intervention is not recommended for the management of COVID-19-associated cardiogenic shock.
Primary Prevention
- There are no established measures for the primary prevention of COVID-19-associated cardiogenic shock.
For primary preventive measures of COVID-19, click here.
Secondary Prevention
- There are no established measures for the secondary prevention of COVID-19-associated myocarditis.
For secondary preventive measures of [COVID-19], click here.
References
- ↑ https://www.cdc.gov/coronavirus/2019-ncov/about/index.html. Missing or empty
|title=(help) - ↑ Lu, Jian; Cui, Jie; Qian, Zhaohui; Wang, Yirong; Zhang, Hong; Duan, Yuange; Wu, Xinkai; Yao, Xinmin; Song, Yuhe; Li, Xiang; Wu, Changcheng; Tang, Xiaolu (2020). "On the origin and continuing evolution of SARS-CoV-2". National Science Review. doi:10.1093/nsr/nwaa036. ISSN 2095-5138.
- ↑ 4.0 4.1 4.2 Tavazzi, Guido; Pellegrini, Carlo; Maurelli, Marco; Belliato, Mirko; Sciutti, Fabio; Bottazzi, Andrea; Sepe, Paola Alessandra; Resasco, Tullia; Camporotondo, Rita; Bruno, Raffaele; Baldanti, Fausto; Paolucci, Stefania; Pelenghi, Stefano; Iotti, Giorgio Antonio; Mojoli, Francesco; Arbustini, Eloisa (2020). "Myocardial localization of coronavirus in COVID‐19 cardiogenic shock". European Journal of Heart Failure. 22 (5): 911–915. doi:10.1002/ejhf.1828. ISSN 1388-9842.
- ↑ Siddiqi, Hasan K.; Mehra, Mandeep R. (2020). "COVID-19 illness in native and immunosuppressed states: A clinical–therapeutic staging proposal". The Journal of Heart and Lung Transplantation. 39 (5): 405–407. doi:10.1016/j.healun.2020.03.012. ISSN 1053-2498.
- ↑ Ye, Qing; Wang, Bili; Mao, Jianhua (2020). "The pathogenesis and treatment of the `Cytokine Storm' in COVID-19". Journal of Infection. 80 (6): 607–613. doi:10.1016/j.jinf.2020.03.037. ISSN 0163-4453.
- ↑ Mahajan, Kunal; Chandra, K.Sarat (2020). "Cardiovascular comorbidities and complications associated with coronavirus disease 2019". Medical Journal Armed Forces India. doi:10.1016/j.mjafi.2020.05.004. ISSN 0377-1237.
- ↑ Belhadjer, Zahra; Méot, Mathilde; Bajolle, Fanny; Khraiche, Diala; Legendre, Antoine; Abakka, Samya; Auriau, Johanne; Grimaud, Marion; Oualha, Mehdi; Beghetti, Maurice; Wacker, Julie; Ovaert, Caroline; Hascoet, Sebastien; Selegny, Maëlle; Malekzadeh-Milani, Sophie; Maltret, Alice; Bosser, Gilles; Giroux, Nathan; Bonnemains, Laurent; Bordet, Jeanne; Di Filippo, Sylvie; Mauran, Pierre; Falcon-Eicher, Sylvie; Thambo, Jean-Benoît; Lefort, Bruno; Moceri, Pamela; Houyel, Lucile; Renolleau, Sylvain; Bonnet, Damien (2020). "Acute heart failure in multisystem inflammatory syndrome in children (MIS-C) in the context of global SARS-CoV-2 pandemic". Circulation. doi:10.1161/CIRCULATIONAHA.120.048360. ISSN 0009-7322.
- ↑ Boukhris, Marouane; Hillani, Ali; Moroni, Francesco; Annabi, Mohamed Salah; Addad, Faouzi; Ribeiro, Marcelo Harada; Mansour, Samer; Zhao, Xiaohui; Ybarra, Luiz Fernando; Abbate, Antonio; Vilca, Luz Maria; Azzalini, Lorenzo (2020). "Cardiovascular Implications of the COVID-19 Pandemic: A Global Perspective". Canadian Journal of Cardiology. doi:10.1016/j.cjca.2020.05.018. ISSN 0828-282X.
- ↑ Rajagopal, Keshava; Keller, Steven P.; Akkanti, Bindu; Bime, Christian; Loyalka, Pranav; Cheema, Faisal H.; Zwischenberger, Joseph B.; El Banayosy, Aly; Pappalardo, Federico; Slaughter, Mark S.; Slepian, Marvin J. (2020). "Advanced Pulmonary and Cardiac Support of COVID-19 Patients". Circulation: Heart Failure. 13 (5). doi:10.1161/CIRCHEARTFAILURE.120.007175. ISSN 1941-3289.
- ↑ Jameson, J (2018). Harrison's principles of internal medicine. New York: McGraw-Hill Education. ISBN 1259644030.
- ↑ Arentz M, Yim E, Klaff L, Lokhandwala S, Riedo FX, Chong M; et al. (2020). "Characteristics and Outcomes of 21 Critically Ill Patients With COVID-19 in Washington State". JAMA. doi:10.1001/jama.2020.4326. PMC 7082763 Check
|pmc=value (help). PMID 32191259 Check|pmid=value (help). - ↑ 13.0 13.1 Sánchez-Recalde, Ángel; Solano-López, Jorge; Miguelena-Hycka, Javier; Martín-Pinacho, Jesús Javier; Sanmartín, Marcelo; Zamorano, José L. (2020). "COVID-19 and cardiogenic shock. Different cardiovascular presentations with high mortality". Revista Española de Cardiología (English Edition). doi:10.1016/j.rec.2020.04.012. ISSN 1885-5857.
- ↑ 14.0 14.1 Yang X, Yu Y, Xu J, Shu H, Xia J, Liu H; et al. (2020). "Clinical course and outcomes of critically ill patients with SARS-CoV-2 pneumonia in Wuhan, China: a single-centered, retrospective, observational study". Lancet Respir Med. 8 (5): 475–481. doi:10.1016/S2213-2600(20)30079-5. PMC 7102538 Check
|pmc=value (help). PMID 32105632 Check|pmid=value (help). - ↑ 15.0 15.1 Dhakal, Bishnu P.; Sweitzer, Nancy K.; Indik, Julia H.; Acharya, Deepak; William, Preethi (2020). "SARS-CoV-2 Infection and Cardiovascular Disease: COVID-19 Heart". Heart, Lung and Circulation. doi:10.1016/j.hlc.2020.05.101. ISSN 1443-9506.
- ↑ Tse, FirstName (2011). Oxford Desk Reference : Cardiology. Oxford: OUP Oxford. ISBN 978-0-19-956809-3.
- ↑ 17.0 17.1 Lal, Sean; Hayward, Christopher S.; De Pasquale, Carmine; Kaye, David; Javorsky, George; Bergin, Peter; Atherton, John J.; Ilton, Marcus K.; Weintraub, Robert G.; Nair, Priya; Rudas, Mate; Dembo, Lawrence; Doughty, Robert N.; Kumarasinghe, Gayathri; Juergens, Craig; Bannon, Paul G.; Bart, Nicole K.; Chow, Clara K.; Lattimore, Jo-Dee; Kritharides, Leonard; Totaro, Richard; Macdonald, Peter S. (2020). "COVID-19 and Acute Heart Failure: Screening the Critically Ill – A Position Statement of the Cardiac Society of Australia and New Zealand (CSANZ)". Heart, Lung and Circulation. doi:10.1016/j.hlc.2020.04.005. ISSN 1443-9506.
- ↑ Aboughdir, Maryam; Kirwin, Thomas; Abdul Khader, Ashiq; Wang, Brian (2020). "Prognostic Value of Cardiovascular Biomarkers in COVID-19: A Review". Viruses. 12 (5): 527. doi:10.3390/v12050527. ISSN 1999-4915.
- ↑ Tse, FirstName (2011). Oxford Desk Reference : Cardiology. Oxford: OUP Oxford. ISBN 978-0-19-956809-3.
- ↑ 20.0 20.1 Driggin, Elissa; Madhavan, Mahesh V.; Bikdeli, Behnood; Chuich, Taylor; Laracy, Justin; Biondi-Zoccai, Giuseppe; Brown, Tyler S.; Der Nigoghossian, Caroline; Zidar, David A.; Haythe, Jennifer; Brodie, Daniel; Beckman, Joshua A.; Kirtane, Ajay J.; Stone, Gregg W.; Krumholz, Harlan M.; Parikh, Sahil A. (2020). "Cardiovascular Considerations for Patients, Health Care Workers, and Health Systems During the COVID-19 Pandemic". Journal of the American College of Cardiology. 75 (18): 2352–2371. doi:10.1016/j.jacc.2020.03.031. ISSN 0735-1097.
- ↑ 21.0 21.1 Dhakal BP, Sweitzer NK, Indik JH, Acharya D, William P (2020). "SARS-CoV-2 Infection and Cardiovascular Disease: COVID-19 Heart". Heart Lung Circ. doi:10.1016/j.hlc.2020.05.101. PMC 7274628 Check
|pmc=value (help). PMID 32601020 Check|pmid=value (help). - ↑ MacLaren, Graeme; Fisher, Dale; Brodie, Daniel (2020). "Preparing for the Most Critically Ill Patients With COVID-19". JAMA. 323 (13): 1245. doi:10.1001/jama.2020.2342. ISSN 0098-7484.