protocol and management acs on covid 19 - perki surabaya · shock, arrythmia, acute...

PROTOCOL AND MANAGEMENT ACS on COVID 19

Dhani Tri Wahyu Nugroho,MD

Cardiologist

RSU Wahidin Sudirohusodo Mojokerto

Introduction

✓Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) causing coronavirus disease 2019 (COVID-19) has reached pandemic levels;

✓Patients with cardiovascular (CV) risk factors and established cardiovascular disease (CVD) represent a vulnerable population when suffering from COVID-19;

✓Patients with cardiac injury in the context of COVID-19 have an increased risk of morbidity and mortality.

Data as received by WHO from national authorities by 10:00 CEST, 16 July 2020

Covid-19 and the Cardiovascular system

✓Older Age

✓Comorbidities CVD, lung renal, diabetes

✓Systemic inflammation

✓Coagulation abnormality

✓Severe illness & multiorgan defunction

✓ Immobility

+✓Myocardial injury & Myocarditis

✓Acute myocardial infraction

✓CHF & Cardiomyopathy

✓Arrhythmias

✓Shock and cardiac arrest

✓Venous Thromboembolic event

Risks Complication

Source: The American Journal of Emergency Medicine 2020 381504-1507DOI: (10.1016/j.ajem.2020.04.048)

COVID-19 is associated with a number of cardiovascular complications, including myocardial injury and myocarditis, AMI, heart failure, dysrhythmias, and VTE.

Coronavirus and Cardiovascular disease

✓ Coronavirus, including severe acute respiratory (SARS), middle east respiratory syndrome and COVID-19, have been associated with a significant burden of CV comorbidities and complications such as hypertension, myocardial injury, acute cardiac injury, shock, arrythmia, acute myocardiacditis, acute heart failure and cardiac arrest

Source: Int J Cardiol. 2020 Jun 15; 309: 70–77; The cardiovascular burden of coronavirus disease 2019 (COVID-19) with a focus on congenital heart disease Published online 2020 Mar 28. doi: 10.1016/j.ijcard.2020.03.063

Source: Jama Cardiology Publish online March 22, 2020

Algorithms for a suspect Acute CV Disease

✓ .

Source: Esc Guidance ESC Guidance for the Diagnosis and Management of CV Disease during the COVID-19 Pandemic. 10 June 2020

Patients in need of hospital admission for acute CVD with concomitant possible/probable SARS-CoV-2 infectionshould rapidly undergo testing and be managed as SARS-CoV-2 infected until they have two negative tests within 48 hours.

Diagnosis of Cardiovascular Conditions in COVID-19 Patients

Clinical Presentation

Chest Pain

Dyspnoea, Cough, Respiratory distress

Cardiogenic Shock

Electrocardiogram

Non-Invasive Imaging

• Chest pain and breathlessness is a frequent symptom inCOVID-19 infection;

• Chronic and acute coronary syndrome presentations canbe associated with respiratory symptoms.

• Dyspnoea (shortness of breath) is one of the typicalsymptoms in COVID-19

• Cough is present in 59.4–81.1% of patients with COVID-19, irrespective of disease severity.

• In COVID-19 patients with impaired end-organ perfusion at risk of cardiogenicshock (CS) (e.g. large acute myocardial infarction [AMI]), consider also sepsis aspossible or mixed aetiology;

•Myocarditis should be considered as precipitating cause of CS.

• no specific ECG changes have been described in patients with SARS-CoV-2 infection.although ST-segment elevation in the setting of myocarditis have been describe.

• Non-urgent or elective cardiac imaging should not be performed routinely in patientswith suspected or confirmed COVID-19 infection.

• non-urgent or elective exams should be postponed until the COVID-19 infection hasceased


Fourth Universal Definition of Myocardial Infarction (2018). J Am Coll Cardiol 2018;Aug 25

Biomarkers

• Cardiomyocyte injury, as quantified by cardiac troponin T/I concentrations, and haemodynamic

stress, as quantified by B-type natriuretic peptide (BNP) and N-terminal B type natriuretic peptide

(NT-proBNP) concentrations, may occur in COVID-19 infections

• In patients hospitalized with COVID-19, mild elevations in cardiac troponin T/I and/or BNP/NT-

proBNP concentrations are in general the result of pre-existing cardiac disease and/or the acute

injury/stress related to COVID-19 do NOT require work-up and/or treatment for Type 1 myocardial

infarction [T1MI])

• It is suggested to measure cardiac troponin T/I concentrations only if the diagnosis of T1MI is being

considered on clinical grounds, or in new onset LV dysfunction

• Serial measurements of D-dimers may help physicians in the selection of patients for VTE-imaging

and/or the use of higher than prophylactic doses of anticoagulation

Cardiac Troponin I/T in patients with COVID-19 infection• COVID-19 is a viral pneumonia that may result in severe systemic inflammation and ARDS, and both

conditions have profound effects on the heart.• Cohort studies from patients hospitalized with COVID-19 in China showed that 5–25% of patients had

elevations in cardiac troponin T/I


Non-Invasive Imaging

• Do not perform routine cardiac imaging

• Prevent contamination

• Perform imaging studies if the management is likely to be impacted by imaging results

• Re-evaluate imaging technique based on diagnostic and infectious risk

• The imaging protocols should be kept as short as possible (if possible POCUS)

Emergency Department

Emergency Department

• A rearrangement of the ED is mandatory to separate suspected COVID-19 patients from patients without SARS-CoV-2 infection;

• Local protocols to rapidly triage patients with respiratory symptoms Patients with mild, stable diseases should be promptly discharged.

• A checklist should be adopted to quickly differentiation patients with possible COVID-19 infection from non infected patients


Intensive Care Unit&Intermediate Care Unit

Intensive Care Unit&Intermediate Care Unit

• Non-COCID Patients with acute CVDs should be preferably admitted to COVID-19 free ICUs/ICCUs

• Care of COVID-19 patients with severe CVDs might be downgraded to lower intensity levels, if the patients prognosis is poor and ICU/ICCU beds are in short supply.


Management STE- ACS during COVID-19➢ The maximum delay from STEMI

diagnosis to reperfusion of 120minutes should remain the goal forreperfusion therapy under thefollowing considerations:

1. Primary PCI remains thereperfusion therapy of choice iffeasible within this time frame andperformed in facilities approved forthe treatment of COVID-19 patientsin a safe manner for healthcareproviders and other patients;

2. Primary PCI pathways may bedelayed during the pandemic (upto 60 minutes – according tomultiples experiences) due todelays in the delivery of care andthe implementation of protectivemeasures;

3. If the target time cannot be metand fibrinolysis is notcontraindicated, fibrinolysis shouldthen become first line therapy;


ST-Segment Elevation Myocardial Infraction

✓ Reperfusion therapy remains indicated in patients with symptom of ischemia of <12 hours duration and persistent ST-Segment elevation in at least two contiguous ECG leads.

✓ In the absence of previous SARS-Co-V2 testing, all STEMI patients should be managed as if they are COVID-19 positive. The safety of HCP should be ensure.

STEMI Diagnosis in COVID-19 Patients

Source: Mahmud et. Al. Management of acute myocardial infarction during the COVID-19 pandemicy, Journal the American College of Cardiology. 17 April 2020.

STEMI Guidance at Non-PCI Facility

Source: Mahmud et. Al. Management of acute myocardial infarction during the COVID-19 pandemicy, Journal the American College of Cardiology. 17 April 2020.

Recommendation for Fibrinolytic therapy


Management NSTE ACS during Covid-19


Source: Eur Heart J Qual Care Clin Outcomes . 2020 May 7;qcaa038. doi: 10.1093/ehjqcco/qcaa038.

Strategical categorization of invasive cardiac procedure during the pandemic


CASE 1• A 57-years old woman with hypertension and

obesity was admitted due to dyspneu. ECG showed ischaemia at V4 – V6, I and AVL. Troponin I was positive. Chest X-ray showed infiltrate paracardial dextra with congestive pulmonum. Laboratory finding with leucocytosis with creatinine serum 4.2 mg/dl (eGFR 12 ml/min/1.73m2).

• Patient give anticoagulant enoxaparin due to eGFR below 30 with dose 1 x 90mg sc and heart failure treatment

• Patient discharge after 7 days treatment of enoxaparin with creatinine serum 1.0 mg/dl

CASE 2• A 52-years old woman with hypertension and was

admitted due to chest pain. ECG showed ST segment elevation II, III and AVF. Troponin I was negative. Chest X-ray showed infiltrate paracardial dextra with cardiomegaly. Laboratory finding with Anti SARS-CoV-2-IgM Reaktif.

• Patient immediately reperfusion using streptokinase during observation at ED isolation room. After thrombolytic therapy given anticoagulant fondaparinux until 7 days.

• Patient discharge after 11 days treatment after 2nd nasopharyngeal swab was negative.

ECG ER

ECG Discharge

This finding is in line with other results from another meta-analysis from Udell et al., which showed that the influenza vaccine given to high-risk patients, such as patients with CAD, reduced their risk of a major adverse cardiovascular event (MACE) (patients treated with influenza vaccine and MACE (2.9%) vs. patients treated with placebo or control and MACE (4.7%); RR, 0.64 (95% CI: 0.48–0.86), p = 0.003) [62]. Therefore, current European guidelines on the diagnosis and management of chronic coronary syndromes recommend annual influenza

vaccination in order to improve prevention of AMI in patients with CAD and decrease CV mortality. Eur. Heart J. 2020, 41, 407–477

protocol and management acs on covid 19 - perki surabaya · shock, arrythmia, acute...

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