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Home , Bradycardia, Sinus bradycardia

2/10/2021

Neika Coughlin APRN-BC

COVID-19 Impact

• From January 1, 2020-June 2, 2020: • Hospitalizations for acute CV conditions have declined • avoiding hospitals • deferral of outpt visits, diagnostic studies, semi-elective procedures • 397,042 CV deaths • Increased ischemic and HTN related deaths (NYC, NY, NJ, MI, IL) • 199,311 (1/1/2020-3/17,2020) vs 197, 731 (3/18-6/2, 2020) • Increased home deaths • Decreased hospitalizations for MI, HF, CVA • less cardiac catheterizations and STEMI activations • Decreased response times, reduction in bystander CPR=decreased survival post

1 2/10/2021

SARS-CoV-2 & RAAS

Role of the ACE2 receptor

2 2/10/2021

Potential Sars-CoV-2 Cardiovascular Effects

COVID -19 Cardiovascular Complications

• ACS/MI NSTEMI type II • Systolic dysfunction • Diastolic dysfunction • • • • Paroxsymal atrial • ->Acute Cor Pulmonale • •

3 2/10/2021

ACS/MI

• ACS/STEMI • acute occlusion of coronary

• ACS/NSTEMI • blockage in minor artery or partial obstruction of a major coronary artery • ST-T changes • • Elevated hs troponin

• NSTEMI type II • secondary to from a supply-demand mismatch • , inflammation, anemia

4 2/10/2021

hs Troponin What Does It Mean?

• Sex specific ranges • Female <=14ng/mL • Male <=22ng/mL

• hs Troponin is 1000x Troponin T • i.e. hs Troponin 682ng/L = Troponin T 0.68ng/mL

Causes of elevated hs Troponin

• Noncoronary ischemia • • hypoxia • hypoperfusion • PE • CT surgery • Myocardial injury with no ischemia • Renal failure • sepsis • infiltrative diseases • acute respiratory failure • stroke • SAH

5 2/10/2021

Causes of elevated hs Troponin

• Other • stress (Takotsubo) • myocarditis • • rhabomyolysis • hypertrophic cardiomyopathy • peripartum cardiomyopathy • failure, malignancy

STEMI

• 1-2mm ST elevation in 2 contiguous leads • new LBBB • chest pain

6 2/10/2021

ACS/NSTEMI

• Chest pain • ST-T changes • inversion • ST depression • Elevated hs troponin

Heart Failure in COVIDSystolic Heart-19 Failure

• Systolic • Acute/acute on chronic • Due to MI, myocarditis • Stress cardiomyopathy (Takotsubo) • Hypoxia • Infection

7 2/10/2021

Systolic Heart Failure

• Diurese cautiously • Guideline directed therapy • Beta blockers • ACE/ARB/ARNI • Entresto • Spironolactone

Systolic Heart FailureTreatment at Discharge

• Guideline directed therapy as BP and renal function allow: • Beta blockers • ACE/ARB/ARNI • Entresto • Spironolactone • Consider device therapy/LifeVest, if indicated

8 2/10/2021

Heart Failure in DiastolicCOVID Heart-19 Failure

• Elderly, especially females • Hypertension • Tachycardia • • with RVR • Hypoxia

Heart Failure in COVID-19

• Acute cor pulmonale • Right heart failure caused by sudden increase in resistance to blood flow in the pulmonary circulation • Pulmonary embolism • COPD

9 2/10/2021

Acute Cor PulmonaleCauses

• Pulmonary embolus • ARDS • RV infarction • Myocarditis • COPD

Acute Cor PulmonalePresentation

• Chest pain • Dyspnea • Tachypnea • Hypoxia • Hypotension

10 2/10/2021

Acute Cor PulmonaleDiagnosis

• elevated d-dimer • elevated hs Troponin • ST-T changes • elevated proBNP • RV dysfunction on echo • Elevated pulmonary artery systolic pressure (RVSP > 25mmHg)

Acute Cor PulmonaleTreatment

• Treat underlying cause • Maintain adequate preload • Fluids for hypotension • Vasopressors

11 2/10/2021

Myocarditis Causes

• SARS-CoV-2

MyocarditisInflammatory disease of the Myocardium

• Hx of viral infection within the past 3-4 weeks (COVID long haulers) • Fatigue • Progressive dyspnea • Fever • Myalgias • chest pain • heart failure • • • Sudden death

12 2/10/2021

Myocarditis Diagnosis

• EKG • hs Troponin • proBNP • CBC-> increased eosinophils • ESR/hsCRP • CXR • Echocardiogram • Cardiac catheterization -> myocardial biopsy • Cardiac MRI

Myocarditis Treatment

• Treat cause • If decreased LV function begin guideline directed therapy • Treat arrhythmias

13 2/10/2021

Arrhythmias

• Paroxysmal atrial fibrillation • Bradycardia • • • Tachycardia • Ventricular arrhythmias

Paroxysmal Atrial FibrillationPAF

• Increased risk with age alone • Increased risk with: • pulmonary disease • hypoxia • acute illness • infection • pulmonary emboli

14 2/10/2021

PAF Treatment

• Atrial fibrillation protocol • Identify underlying cause • CHA2DS2-VASc score • Anti-coagulation for Stroke prevention

Bradycardia Sinus bradycardia, Heart blocks

• Myocarditis with inflammation of the electrical conduction system • Medications • Beta blockers • Calcium channel blockers • Precedex • Hypoxia • Increased

15 2/10/2021

Bradyarrhythmias

• Treat cause • Adjust medications • If pt hemodynamically stable, continue to monitor • If heart block and asymptomatic, monitor for progression • Consider pacemaker

Sinus Tachycardia

• Compensatory mechanism • Allow permissive tachycardia • Treat underlying cause • Fever • Hypoxia • Infection • Diurese • Pain • Anemia

16 2/10/2021

VentricularPVCs, Ventricular Arrhythmias Tachycardia,

• Occur in the presence of: • ACS • Heart failure • Myocarditis

Ventricular ArrhythmiasTreatment

• ACLS protocols acutely • • If EF < 35%, consider LifeVest vs ICD prior to discharge

• Hydroxychloroquine • QT prolongation

17 2/10/2021

Potential Sars-CoV-2 Cardiovascular Effects

Questions

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