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
In Italy, for the first time in a 69-year-old patient, who was presented with cardiogenic shock due to COVID-19 infection myocardial involvement by viral particles was pathologically proved through biopsy. Two mechanisms are more probable to contribute to cardiogenic shock related to Covid-19 that includes direct invasion and cytokine storm. According to a recent study, one-third of critically ill patients with COVID-19 of an ICU in Washington State had clinical signs of cardiogenic shock and cardiomyopathy. According to an observational study in China, COVID-19 associated cardiogenic shock has a poor prognosis.
Historical Perspective
- On March 12, 2020, the WHO declared coronavirus disease 2019(COVID-19) outbreak to be a pandemic.
- In Italy, for the first time in a 69-year-old patient, who was presented with cardiogenic shock due to COVID-19 infection, myocardial involvement by viral particles was pathologically proved through biopsy. [1]
Classification
- There is no specific classification for COVID-19 associated cardiogenic shock.
Pathophysiology
Two mechanisms are more probable to contribute to cardiogenic shock related to Covid-19:[2] [3]
- Direct invasion of the virus into the cardiomyocytes
- Cytokine storm activated by T helper cells (Th1 and Th2) and trigger a systemic hyperinflammatory response
Differentiating COVID-19 associated cardiogenic shock from other Diseases
- Cardiogenic shock related to COVID-19 must be differentiated from other diseases which include distributive shock, hypovolemic shock and mixed (distributive and cardiogenic shock). [4] [5] Some hemodynamic parameters would help differentiate significant types of shock: [6]
| style="background: #4479BA; text-align: center;" | Cardiac output | Pulmonary Capillary Wedge Pressure | Systemic Vascular Resistance | Pulmonary artery diastolic pressure | SVO2 |
|---|---|---|---|---|---|
| Septic shock | ↑ | ↓ | ↓ | ↓ | ↓ |
| Hypovolemic shock | ↓ | ↓ | ↑ | ↓ | ↑ |
| Cardiogenic shock | ↓ | ↑↔ | ↑ | ↑ | ↓ |
Epidemiology and Demographics
- According to a recent study, one-third of critically ill patients with COVID-19 of an ICU in Washington State had clinical signs of cardiogenic shock and cardiomyopathy.[7] There are few anecdotal reports of cardiogenic shock related to COVID-19. [1] [8]
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.
Causes
The causes of cardiogenic shock related to COVID-19 might include: [9] [10]
- 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
- Multisystem Inflammatory Syndrome (MIS-C) in children related to COVID-19
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. [11] [12]
Diagnosis
History and Symptoms:
The history of patients presented cardiogenic shock related to COVID-19, according to a few anecdotal reports were different. Some did not have any cardiovascular risk factors.
- A 69-year-old patient from Italy has been reported by Tavazzi et al., as a cardiogenic shock-associated COVID-19 case. The patient had flu-like symptoms when he was hospitalized and quickly deteriorated into respiratory distress and cardiogenic shock. [1]
Four patients with cardiogenic shock complication related to COVID-19 were reported by Sanchez-Recalde, et al. They were hospitalized between 1 March and 15 April 2020 including:[8]
- A 42-year-old woman, who had dyslipidemia as a cardiovascular risk factor
- A 50-year-old man, without any cardiovascular risk factors, admitted by severe bilateral pneumonia related to COVID-19. After a few hours, he developed cardiogenic shock.
- A 75-year-old man did not have any cardiovascular risk factors and was admitted due to dyspnea, chest pain, and bilateral SARS-CoV-2 pneumonia.
- A 37-year-old woman, obese with a history of deep venous thrombosis, had symptoms of dyspnea and chest pain
Physical Examination
- 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 COVID-19 patient cardiogenic shock should be considered.[12]
- Physical examination may be remarkable for Covid-19 associated cardiogenic shock:[13]
- 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 shock types. Two tests are more valuable to clarify this, which are elevated in cardiogenic shock related to COVID-19 : [14]
- serum brain natriuretic peptide (BNP)
- Troponin
- The increase of some biomarkers demonstrates poor prognosis, increased mortality, and more severe symptoms in COVID-19 patients:[15]
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 [16]
Echocardiography or Ultrasound
- Echocardiography is an appropriate way, in order to identify the extent of cardiac involvement in COVID-19 associated cardiogenic shock cases.[14]
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 [17]
Mechanical Support:
- In treating patients with cardiogenic shock related to COVID-19, the efficacy of extracorporeal membrane oxygenation (ECMO) is indistinct. It might be used in most critically ill and highly selective patients. Although specialists utilizing ECMO and mechanical circulatory support devices, most of the cases have cardiogenic shock related to COVID-19 die, since 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. [18] [11]
Prevention
- There are no established measures for the primery prevention of COVID-19-associated cardiogenic shock.
- For primary preventive measures of COVID-19, click here.
References
- ↑ 1.0 1.1 1.2 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.
- ↑ 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). - ↑ 8.0 8.1 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.
- ↑ 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.
- ↑ 11.0 11.1 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). - ↑ 12.0 12.1 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.
- ↑ 14.0 14.1 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.
- ↑ 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.