- Cardiomyopathy in 33%
- Coinfection: 5.8% of all comers, 21-80% of ICU patients. Most commonly influenza
- Chloroquine – QT prolongation
- Lopinavir/ritonavir – drug/drug interactions, especially with DOACs, P2Y12 inhibitors, and statins
- Cardiovascular – acute myocardial injury. Myocarditis with circulatory failure as primary cause of death (7%), myocarditis as contributing cause of death (33%). Type 1 ACS. Acute heart failure (23% of COVID-19 patients) – unknown if exacerbation of underlying CM or new disease. Pulmonary hypertension.
Driggin E, Madhavan MV, Bikdeli B, et al. Cardiovascular Considerations for Patients, Health Care Workers, and Health Systems During the Coronavirus Disease 2019 (COVID-19) Pandemic. J Am Coll Cardiol. Journal pre-proof available: http://www.onlinejacc.org/content/early/2020/03/18/j.jacc.2020.03.031. Accessed March 20, 2020. More Info
- Acute myocardial injury, myocarditis, arrhythmias, and venous thromboembolism
- Troponin higher in patients with severe COVID-19 compared to non severe disease based on metanalysis (341 pts, 4 studies)
- AMI present in 7-17% of hospitalized patients, 22.2% of ICU patients, and 59% of those who died
- Same 7% and 33% figures as corependium (of 68 pts who died out of 150 COVID pts, 7% of deaths attributed to myocarditis with circulatory failure and 33% of cases myocarditis contributed to patient death
- Risk of plaque instability and Type I MI in COVID is strictly theoretical at this point, but there is data showing increased risk of this after influenza and other coronavirus infections. Mechanism is thought to related to overactive inflammatory response.
- Be prepared for clinical and management uncertaininty in the setting of STEMI presentation when COVID infection is a consideration
- Palpitations are part of presenting symptomology in 7.3% of patients
- Arrhythmia in 16.7% of hospitalized COVID-19 pts, and in 44.4% of ICU COVID-19 pts. Details of the arrhythmias are unknown
- Myocarditis may lead to malignant tachyarrhythmias
- VTE incidence in COVID is unknown, but suspected to be elevated relative to non-COVID patients. Abnormal coagulation parameters (d-dimer, FSP, and other signs of DIC) are common in non-survivors
Guan WJ, Ni ZY, Hu Y, et al. Clinical Characteristics of Coronavirus Disease 2019 in China [published online ahead of print, 2020 Feb 28]. N Engl J Med. 2020;10.1056/NEJMoa2002032. doi:10.1056/NEJMoa2002032 More Info
- Regarding traditional
septic complications:
- Septic shock 1.1%
- ARDS 3.4%
- AKI 0.5%
- DIC 0.1%
- Rhabdo 0.2%
National Center for Immunization and Respiratory Diseases (NCIRD), Division of Viral Diseases. Coronavirus Disease 2019 (COVID-19). Healthcare Professionals: Frequently Asked Questions and Answers. CDC 24-7 Organization website. https://www.cdc.gov/coronavirus/2019-ncov/hcp/faq.html Published/Update Febraury 21, 2020. Updated March 10, 2020. Accessed March 11, 2020. More Info
- Reinfection risk after recovery is unknown
Wu Z, McGoogan JM. Characteristics of and Important Lessons From the Coronavirus Disease 2019 (COVID-19) Outbreak in China: Summary of a Report of 72 314 Cases From the Chinese Center for Disease Control and Prevention [published online ahead of print, 2020 Feb 24]. JAMA. 2020;10.1001/jama.2020.2648. doi:10.1001/jama.2020.2648 More Info
Young BE, Ong SWX, Kalimuddin S, et al. Epidemiologic Features and Clinical Course of Patients Infected With SARS-CoV-2 in Singapore. JAMA. Published online March 03, 2020. doi:10.1001/jama.2020.3204. https://jamanetwork.com/journals/jama/fullarticle/2762688 Accessed March 18, 2020. More Info
Zhou F, Yu T, Du R, et al. Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study [published online ahead of print, 2020 Mar 11] [published correction appears in Lancet. 2020 Mar 12;:]. Lancet. 2020;S0140-6736(20)30566-3. doi:10.1016/S0140-6736(20)30566-3 More Info
- Sepsis 59%
- Respiratory failure 54%
- ARDS 31%
- Heart failure 23%
- Septic shock 20%
- Coagulopathy 19%
- Acute cardiac injury 17%
- AKI 15%
- Secondary infection 15%
Arentz M, Yim E, Klaff L, et al. Characteristics and Outcomes of 21 Critically Ill Patients With COVID-19 in Washington State. JAMA. Published online March 19, 2020. doi:10.1001/jama.2020.4326. https://jamanetwork.com/journals/jama/fullarticle/2763485 Accessed March 20, 2020. More Info
- Complications in ICU patients (small 21 patient series)
- ARDS 95.2%
- Need for NIPPV 19%
- Need for HFNC > 15 L/min 4.8%
- Need for mechanical ventilation 71%
- Need for vasopressors 67%
- Bacterial co-infection 4.8%
- Viral co-infection 14.3%
- Acute renal failure 19.1%
- Cardiomyopathy 33.3%
- Acute hepatic injury 14.3%
- Seizures 4.8%
- Mortality 52.4%
Wang D, Hu B, Hu C, et al. Clinical Characteristics of 138 Hospitalized Patients With 2019 Novel Coronavirus-Infected Pneumonia in Wuhan, China. JAMA. 2020;
- 138 hospitalized patients in Wuhan
- Complications:
- Shock 8.7%
- Acute cardiac injury 7.2%
- Arrhythmia 16.7%
- ARDS 19.6%
- AKI 3.6%
Zheng YY, Ma YT, Zhang JY, Xie X. COVID-19 and the cardiovascular system. Nat Rev Cardiol. 2020
- 12 year follow up data from SARS recoverers shows high rates of glucose and lipid dysmetabolism, as well as cardiovascular disease.
Alhazzani et al. Surviving Sepsis Campaign: Guidelines on the Management of Critically Ill Adults with Coronavirus Disease 2019 (COVID-19). Surviving Sepsis Campaign. https://www.sccm.org/getattachment/Disaster/SSC-COVID19-Critical-Care-Guidelines.pdf
- Cytokine storm and secondary HLH are recognized complications. Incidence is unknown.
Zhang C, Shi L, Wang FS. Liver injury in COVID-19: management and challenges. Lancet Gastroenterol Hepatol. 2020
- Incidence of abnormal LFTs in COVID varies significantly by study, but may be as high as 62%.
- Some degree of viral infection of liver cells is suspected
David Gordon, MD