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: : Sara Zand, M.D.[2] Alieh Behjat, M.D.[3]

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

SARS-COV-2 or COVID-19 is a specific strain of coronavirus that is responsible for an ongoing global pandemic. COVID-19 may lead to respiratory disease and also multiorgan dysfunction including biventricular failure and profound shock and life threatening cardiogenic shock. Cardiogenic shock shoulb be considered while cardiac ethiology is evident in patients with persistent hypotesion despite fluide resuscitation in the presence of end organs dysfunction. Cardiogenic shock may present as a consequence of cytokine storm pathway or direct invasion of cardiovascular system by virus via ACE2 receptos on the cells. Cardiogenic shock may progress to develop quicky in covid-19 patients and any delay for diagnosis and treatment of such patients will increase mortality rate. In mild or severe types of covid-19 with sudden collapse of hemodynamic, considering different causes of cardiogenic shock including fulminant myocarditis, acute STEMI, massive pulmonary thromboembolism, stress cardiomyopathy, are helpful to clinical approach and quickly initiation of treatment. Mortality rate of covid-19 patients with cardiogenic shock among reported cases in literature was 75% despite use of pharmacological and mechanichal hemodynamic support.

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.
• On March 12, 2020, the WHO declared the Coronavirus disease 2019 (COVID-19) outbreak to be a pandemic.
• 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.

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:

• 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

Common causes of cardiogenic shock in patients with covid-19 include:

• Acute myocarditis
• Acute coronary syndrome
• Stress cardiomyopathy
• Pulmonary thromboembolism
• 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:

• Distributive shock
• Hypovolemic shock
• Mixed (distributive and cardiogenic shock).

Some hemodynamic parameters would help differentiate significant types of shock:

	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. There are few anecdotal reports of cardiogenic shock related to COVID-19.

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

• Cardiogenic shock can develop suddenly in covid-19 patients without underlying risk factors of cardiovascular disease.
• If left untreated, patients with cardiogenic shock may progress to develope hemodynamic collapse, death.
• Prognosis is generally poor, and mortality rate of cardiogenic shock in covid-19 reported cases was approximately 75%.
• In spite of using Extracorporeal membrane oxygenation (ECMO), 83% of patients who suffered of cardiogenic shock in covid-19 died.

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 30 minutes,

cardiac index ≤ 2.2L/min per m². pulmonary capillary wedge pressure ≥ 15 mmHg with impaired organ perfusion including:

• Urine output is less than 30 m/hr
• Cool extermities
• Altered mental status
• Serum lactate> 2 mmol/L
• Use of pharmacological or mechanical support to maintain an BP ≥ 90mmHg

History and Symptoms:

• Cardiogenic shock should be considered in covid-19 patients who present with suddenly hypotension, cool extremities, reslesness, shortness of breath, chest discomfort, palpitation.
• Cardiac biomarkers sampling, cardiac monitoring , obtaining ECG, evaluation of cardiac function by echocardiography are considered.
• In the presence of tachyarrhythmia or bradyarrhythmia and evidence of hypotension and pulmonary edema, evaluation about fulminant myocarditis, acute STEMI are warranted.
• In the presence of unilateral or bilateral lower limbs edema and suddenly refractory hypotension , tachycardia, and tachypnea, massive pulmonary thromboembolism should be considered.

• Table bellow shown the clinical characteristics of patients with covid-19 associated with cardiogenic shock:

Age, sex	Cardiovascular history	Symptoms	Timing according to covid-19 infection	Echocardiography, catheterization	Covid-19 severity	Diagnosis	Treatment	Outcome
42 years, female	Dyslipidemia, oral contraceptive	Dyspnea, cough, diarrhea, vomiting, anosmia, dysgeusia suddenly cardiovascular arrest, ventricular arrhythmia storm refractory to antiarrhythmic therapy, sinus rhythm, new LBBB on ECG	12 days	Severe biventricular dysfunction in echocardiography, normal epicardial coronary arteries in coronary angiography, no pulmonary thromboembolism in pulmonary angiography	Mild	Fulminant myocarditis	Cardiopulmonary resuscitation at presentation, implantation of VA-ECMO, intra-aortic counter pulsation for unloading left ventricle, temporary pacemaker implantation	Refractory shock, death
50 years, male	None	Severe respiratory distress, severe hypotension with lateral wall ST segments elevation after admission	8 days	Severe left ventricular dysfunction with akinesia of the basal and midsegments, apical hypercontractility in echocardiography,	Severe bilateral lung pneumonia requiring mechanical ventilation	Inverted takotsubo cardiomyopathy	Mechanical ventilation, hydroxychloroquine, antiretroviral agents, antibiotics,corticosteroids	Survived
75 years, male	None	Chest pain, dyspnea, inferior STEMI, complete heart block, frequent episodes of ventricular fibrillation requiring cardioversion, intubation, mechanical ventilation	2 days	Biventricular failure, predominantly right sided in echocardiography, right coronary artery thrombosis in urgent coronary angiography	Severe bilateral SARSE-COV-2 pneumonia	STEMI, right coronary artery thrombosis	Stenting of right coronary artery	Electromechanical dissociation a few hours after PCI, death
37 years, female	Obese, history of deep vein thrombosis 8 years ago after fracture and immobilization	Dyspnea, chest pain, suddenly developed severe hypotension, S02< 80%	10 days	Urgent CT angiography of pulmonary arteries: bilateral pulmonary thromboembolism, right ventricular dilation	Patchy peripheral lung opacification	Massive pulmonary thromboembolism	Systemic thrombolytic therapy	Cardiogenic shock, death
53 years, male	None	Cough, fever, shortness of breath, tachycardia, tachypnea, cool extremities, J point elevation in inferolatel leads of ECG, low cardiac output calculated by Fick index	Confimed by PCR 5 week ago, treating with supportive therapy at home	LVEF=25%, global hypokinesis, right ventricular dilation with dysfunction in echocardiography, normal epicardial coronary arteries in coronary angiography	Mild pulmonary vascular congestion on CXR, normally otherwise	Covid-19 induced cardiomyopathy	Hydroxychloroquine, isosorbide dinitrate, hydralazine, carvedilol, eplerenone, steroid therapy, inotrope	Improving LVEF to 50% after 4 days of therapy, and LVEF 60% after 10 weeks of therapy, survived
30 years, female	Obesity	Fatigue, shortness of breath, tachycardia, tachypnea, hypotension	Confimed by PCR 9 days ago	LVEF=45%, moderate diffuse hypokinesis, moderate pericardial effusion	Patchy airspace disease in chest CT scan	Covid-19 induced cardiomyopathy	Hydroxychloroquine, vitamin C, zinc, atorvastatin, milrinone , methylprednisolone	Improving LVEF to 55% after 6 weeks of discharge, survived
69 years, male	None	Cough, shortness of breath, weakness, tachypnea, hypotension, suddenly oxygen desaturation	4 days	LVEF=25%, severe diffuse left ventricle hypokinesia	Diffuse bilateral interstitial inflammation, subpleural consolidation	Covid-19 induced cardiomyopathy	Norepinephrine, VA ECMO, IABP, intubation	Increased LVEF to narmal value, few hours after weaning of ECMO died of septic shock due to pseudomonas ,klebsiella

Physical Examination

• Physical examination in covid-19 associated cardiogenic shock include:

• Assessment of consciousness level
• Extremities, warm or cool
• Vital signs (tachycardia and hypotension and tachypnea)
• Evaluation of volume status: CVP (increased JVP), lower limbs edema)
• Skin pallor
• Ascultation of Rale in lung fields and cardiac murmurs

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:
  • 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:
  • cTnT and cTnI levels
  • The association of elevated CK-MB and BNP

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

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.

Echocardiography or Ultrasound

• Echocardiography is an appropriate way to identify the extent of cardiac involvement in COVID-19-associated cardiogenic shock cases.

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.

To view the CT scan findings on COVID-19, click here.

MRI

• Findings of cardiac MRI in the case series of young males with covid-19 and biventricular failure are: (doi:10.1161/CIRCHEARTFAILUREURE.120.007485)

  Mild nonspecific late gadolinium enhancement in some cases

  NO evidence of myocardial edema on T2 weighted imaging

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:

The maistay of therapy of cardiogenic shock in covid-19 patients is respiratory and circulatory support. (doi:10.1016/j.rec.2020.04.012)

• In patients with myocarditis, administration of corticosteroids and immunoglobulins are recommended.
• Cardiogenic shock in the setting of stress cardiomyopathy can be triggered by catecholamine discharge secondary to hypoxia or sepsis and should be managed by mechanical support.
• Treatment of cardiogenic shock due to pulmonary thromboembolism include implantation of VA ECMO, thrombolysis, percutaneous treatment in case of thrombolysis contraindicated or failed.
• In the presence of cardiogenic shock due to acute coronary thrombosis , revascularization by PCI or CABG based on the arterial anatomical involvement are warranted.
• In the case series of young males with covid-19 and cardiogenic shock and biventricular failure with high level of hyperinflammatory biomarkers, use of moderate-dose steroid, anticoagulant, supportive care led to recovery of shock quickly.(doi:10.1161/CIRCHEARTFAILUREURE.120.007485)

• General approach for patients with shock is:
• Fluid resuscitation (crystalloid IV fluids are more efficient than colloid solutions)
• Administration of vasopressors and inotropes to stabilize shock
• Mixed etiologies of shock should be considered in covid-19 infection if hemodynamics not refining, specifically in patients with a previous cardiac abnormality

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.

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.