Covid-19 / Coronavirus

Clinical guidance for cardiology teams

ACC Clinical Bulletin COVID-19 Clinical Guidance for Cardiovascular Teams 

(Adopted from a guidance published by American College of Cardiology on 06/03/2020. The situation will change very quickly and the information below may become obsolete.)

To best serve your patients, protect yourself first!

Current Clinical Context of COVID-19

• The overall case fatality rate (CFR) of COVID-19 remains low at 2.3%, with data indicating lower overall mortality in China outside of the outbreak epicenter in Hubei. In the rest of the world, CFRs ranges between 0.5% in South Korea and 2.7% in Iran. This is situation on 06.03.2020; the information is only provisional and likely to change.

• More than 80% of infected patients experience mild symptoms and recover without intensive medical support.

• Morbidity and mortality increase significantly with age, rising to 8.0% among patients 70-79 and 14.8% in patients over 80.

• Patients with underlying comorbidities are at higher risk of contracting the virus have a worse prognosis. 25% - 50% of COVID-19 patients have underlying medical problems.

• Comorbidities significantly increase case fatality rate: cancer: 5.6%, hypertension: 6.0%, chronic respiratory disease: 6.3%, diabetes mellitus: 7.3%, cardiovascular disease: 10.5%.

Acute Cardiac Complications of COVID-19

• According to a recent report, 16.7% of hospitalized patients developed arrhythmia and 7.2% experienced acute cardiac injury, in addition to other COVID-19 related complications.

• Increased metabolic demand in infected patients can precipitate cardiac complications, such as acute heart failure, myocardial infarction, myocarditis, and cardiac arrest.

• Patients with heart failure, heart rhythm problems, ischaemic ECG changes or cardiomegaly should have echocardiography.

Implications For Patients With Underlying Cardiac Disease

• Make plans for quickly identifying and isolating cardiac patients with relevant symptoms from other patients, including in the ambulatory setting.

• It is reasonable to advise all cardiac patients of the potential increased risk and to encourage additional, reasonable precautions.

• It is important for cardiac patients to remain current with vaccinations, including the pneumococcal vaccine given the increased risk of secondary bacterial infection with COVID-19. Cardiac patients should be vaccinated against influenza in accordance with current guidelines.

• In areas with active COVID-19 outbreaks, it may be reasonable to substitute clinic appointments for telephonic or telehealth consultations for stable cardiac patients to avoid possible nosocomial COVID-19 infection.

• It is reasonable to triage COVID-19 patients according to underlying cardiovascular, diabetic, respiratory, renal, oncological, or other comorbid conditions for prioritized treatment.

• Medical professionals are cautioned that classic symptoms and presentation of myocardial infarction may be masked in the context of COVID-19.

• Fluid administration for viral infection in patients with heart failure should be used cautiously and carefully monitored.

• General immunological health remains important for both medical professionals and patients, including eating well, sleeping and managing stress.

Cardiac-specific Preparedness Recommendations For COVID-19

• Frequent transmission of COVID-19 to medical professionals suggests that usual infectious disease mitigation precautions are insufficient and medical professionals in outbreak areas must be prepared to adopt personal protection measures.

• Medical professionals with limited experience and/or training in personal protective equipment (PPE) should be trained as soon as possible

• Protocols should be developed for the management of myocardial infarction in the context of a COVID-19 outbreak. Particular emphasis should be placed on acute PCI and CABG, including protocols to limit the number of staff in the catheterization labs and operating theatres to a required minimum, use enhanced personal protection, and assess post-procedural sterilization sufficiency.

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