NYC Physicians: A Closer Look at COVID-19’s Cardiovascular Impact

A team of 18 New York City physicians suggest that the novel coronavirus disease 2019 (COVID-19) can involve the cardiovascular system in a variety of ways and provide 4 detailed case studies in the April 3, 2020 edition of Circulation.

New York City has been hit hardest in the US with >160 000 confirmed cases and >5000 deaths as of April 10, 2020; and the researchers noted that although COVID-19 is largely associated with respiratory distress, there is increasing awareness of the cardiovascular manifestations of the disease as well as the impact of comorbid cardiovascular disease (CVD) on outcomes.  

The physicians also wrote that there are evolving considerations for treatment across the spectrum of patients with pre-existing CVD.

The 4 patient cases selected illustrate several of the cardiovascular presentations of COVID-19 observed in New York: chest pain and elevated sinus tachycardia; cardiogenic shock; decompensated heart failure (HF); and the special circumstance of a heart transplant.

The authors included these 8 take-home messages:

1. In patients presenting with what appears to be a typical cardiac syndrome, COVID-19 should be in the differential during the current pandemic (even in the absence of fever or cough).
2. One should have a low threshold to assess for cardiogenic shock in the setting of acute systolic HF related to COVID-19. If inotropic support fails in these patients, authors consider intra-aortic balloon pump as the first line mechanical circulatory support device because it requires the least maintenance from medical support staff.
3. When patients on veno-venous extracorporeal membrane oxygenation for respiratory support develop superimposed cardiogenic shock, the addition of an arterial conduit at relatively low blood flow rates may provide the necessary circulatory support without inducing left ventricular distension.
4. COVID-19 can cause decompensation of underlying HF and may lead to mixed shock. Invasive hemodynamic monitoring, if viable, could help manage the cardiac component of shock in such cases.
5. Medications that prolong the QT interval are being considered for COVID-19 patients and may require closer monitoring in patients with underlying structural CVD.
6. The heart transplant recipient exhibited similar symptoms of COVID-19 as compared to the general population.
7. For transplant patients requiring hospitalization, how to alter the antimetabolite and immunosuppression regimens remains uncertain.
8. COVID-19 pandemic creates a challenge for the management of HF patients on the heart transplant waitlist, forcing physicians to balance the risks of delaying transplant with the risks of donor infection and uncertainty regarding the impact of post-transplant immunosuppression protocols.

“Discriminating between a cardiac or respiratory etiology of symptoms can be challenging since each may present predominantly with dyspnea. It is also critical to recognize when cardiac and pulmonary involvement coexist,” noted authors.