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 cardiac arrest 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 • Tachycardia • Hypotension • Bradycardia • Paroxsymal atrial fibrillation • Pulmonary embolism->Acute Cor Pulmonale • Myocarditis • Endocarditis 3 2/10/2021 ACS/MI • ACS/STEMI • acute occlusion of coronary artery • ACS/NSTEMI • blockage in minor artery or partial obstruction of a major coronary artery • ST-T changes • Chest pain • Elevated hs troponin • NSTEMI type II • secondary to ischemia from a supply-demand mismatch • hypoxia, 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 • shock • 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 cardiomyopathy (Takotsubo) • myocarditis • myopericarditis • rhabomyolysis • hypertrophic cardiomyopathy • peripartum cardiomyopathy • heart 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 • T wave inversion • ST depression • Elevated hs troponin Heart Failure in COVIDSystolic Heart-19 Failure • Systolic heart failure • 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 • Sinus tachycardia • Atrial Fibrillation 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 • Cardiogenic Shock • Arrhythmias • 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 • Sinus bradycardia • Heart block • 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 vagal tone 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, Ventricular Fibrillation • Occur in the presence of: • ACS • Heart failure • Myocarditis Ventricular ArrhythmiasTreatment • ACLS protocols acutely • Amiodarone • If EF < 35%, consider LifeVest vs ICD prior to discharge • Hydroxychloroquine • QT prolongation 17 2/10/2021 Potential Sars-CoV-2 Cardiovascular Effects Questions 18.