Troponin and BNP Use in COVID-19 Mar 18, 2020 Cardiology Magazine Share via: Font Size A A A What are the potential mechanisms underlying troponin elevation with COVID-19 infection? Rise and/or fall of troponin indicating myocardial injury is common among patients with acute respiratory infections and correlated with disease severity. Abnormal troponin values are common among those with COVID-19 infection particularly when testing with a high sensitivity cardiac troponin (hs-cTn) assay. In a recent article summarizing clinical course of patients with COVID-19, detectable hs-cTnI was observed in most patients, and hs-cTnI was significantly elevated in more than half of the patients that died. The mechanisms explaining myocardial injury in those with COVID-19 infection are not fully understood, however in keeping with other severe respiratory illnesses, direct (“non-coronary”) myocardial damage is almost certainly the most common cause. Given presence of abundant distribution of ACE2 – the binding site for the SARS-CoV-2 – in cardiomyocytes, some have postulated that myocarditis might explain rise of hs-cTn in some cases, particularly as acute left ventricular failure has been described in some cases. Lastly, acute myocardial infarction (MI) – either Type 1 MI based plaque rupture triggered by the infection, or Type 2 MI based on supply-demand inequity – is always possible. Importantly, a rise and/or fall of hs-cTn is not sufficient to secure the diagnosis of acute MI, which should be based on clinical judgment, symptoms/signs, and ECG changes. Given the frequency and non-specific nature of abnormal troponin results among patients with COVID-19 infection, clinicians are advised to only measure troponin if the diagnosis of acute MI is being considered on clinical grounds and an abnormal troponin should not be considered evidence for an acute MI without corroborating evidence. What are the potential mechanisms underlying elevation of natriuretic peptides with COVID-19 infection? Natriuretic peptides are biomarkers of myocardial stress and are frequently elevated among patients with severe respiratory illnesses typically in the absence of elevated filling pressures or clinical heart failure. Much like troponin, elevation of BNP or NT-proBNP is associated with an unfavorable course among patients with ARDS. Patients with COVID-19 often demonstrate significant elevation of BNP or NT-proBNP. The significance of this finding is uncertain and should not necessarily trigger an evaluation or treatment for heart failure unless there is clear clinical evidence for the diagnosis. What testing should be performed in COVID-19 patients with acute myocardial injury or abnormal natriuretic peptide results? Given the frequency and non-specific nature of abnormal troponin or natriuretic peptide results among patients with COVID-19 infection, clinicians are advised to only measure troponin or natriuretic peptides if the diagnosis of acute MI or heart failure are being considered on clinical grounds. An abnormal troponin or natriuretic peptide result should not be considered evidence for an acute MI or heart failure without corroborating evidence. Use of echocardiography or coronary angiography for COVID-19 patients with myocardial injury or elevated natriuretic peptide should be restricted to those patients in whom these procedures would be expected to meaningfully affect outcome. Is there a role for antithrombotic (antiplatelet and/or anticoagulant) therapy in acute myocardial injury? No data exist to suggest benefit from anti-platelet or anticoagulant therapy for those with acute myocardial injury with the exception of those with Type 1 MI. This article is authored by James L. Januzzi Jr., MD, FACC.
20 MAR 2020 NSTEMISTEMIOTHER CORONARY INTERVENTIONS COVID-19: Providing ongoing care to patients with cardiovascular disease in a pandemic We are living through a pandemic! A battle: humanity against a bug… The world is facing unprecedented challenges as a result of a bug called COVID-19 (Sars-CoV-2) that has literally gone “viral” across the globe affecting >250K individuals in 183/195 countries, claiming >10,000 lives in a short period of time (as of 15:00 20/3/2020). COVID-19 has disrupted our daily lives, schools/universities shut down, cities/countries in lock down, travel ban, large gatherings including major cardiac scientific society meetings now cancelled, with immense pressure on our health care services and it is heart breaking to witness the devastation caused! But life goes on and as cardiovascular health professionals how do we continue to care for our patients? It appears we will be in this pandemic for a little while longer to say the least from now… How do we get through this and provide as best care to our patients as possible? As we begin to learn a lot about the new virus, COVID-19 or Corona virus, it appears the disease will be mild in most cases (~80%). However given the fact that our ICUs are filling up rapidly with previously healthy young people on ventilators (~5% of COVID-19 infected patients needing ITU care), it is indeed without a doubt a serious threat! Cardiovascular disease remains world’s biggest killer. COVID-19 seems to escalate the risk in our patients with heart disease. Importantly, it seems the older patients with a mean age of 81 years with co-morbidities such as cardiovascular disease, diabetes, hypertension are at the highest risk of mortality as such (1), (2). Approximately 70% of over 70 years of age have died as a result of the viral infection. Increasing odds of in-hospital death was associated with older age (odds ratio 1·10, 95% CI 1·03–1·17, per year increase; p=0·0043)1. A recent review sheds light on Cardiovascular Considerations for Patients, Health Care Workers, and Health Systems During the Coronavirus Disease 2019 (COVID-19) Pandemic (3). Given the virus spreads from person to person (4), it is vital everyone (including those infected, those caring for them, those around them) follow simple procedures such as hand washing, catch it-bin it-kill it procedures and physical/social distancing to contain the virus. The incubation period is on average 5 days for Sars-CoV-2. Managing myocardial infarction in the COVID-19 pandemic Whilst the above approaches (social/physical distancing) are feasible strategies for those with chronic heart conditions, patients needing emergency medical attention for example in the setting of STEMI will need to be admitted for emergency care. We all know that primary percutaneous coronary intervention (PPCI) is the gold standard for STEMI with 30-day mortality for those that were treated with PPCI is ~6%5 much lower than those treated with thrombolysis (6). However we are in the midst of a crisis with high chances of contracting the virus, there is an immediate need for health care professionals to develop/follow their own institutional infection prevention control protection measures, guidelines in the care of such patients. From what we see, from what colleagues share their experiences on social media, it is not always possible to know who is infected and who is not. Some patients with COVID-19 seem to present as STEMI which only gets picked up after a normal diagnostic angiography procedure. With rapid evolution and spread of the disease, this raises the question if all frontline staff treating these patients should be protected. The obvious answer appears ‘Yes’ in the context of shortages of such protective equipment for staff. We did manage heart attacks with thrombolysis in the past but of course this has its own disadvantages of excess bleeding, less reperfusion rates, prolonged hospitalisation etc., which is not what we want right now. We really are in an uncharted territory with an immediate need for innovative/concerted approaches to tackle the situation… The mortality rate post PCI in the setting of NSTEMI is <2% at 30-days (5). In these challenging times it might also be appropriate to determine if patients stabilised on medical therapy could be discharged early and reserve interventional approaches to those unstable patients with ongoing symptoms despite optimal medical therapy. Out-patient clinics and elective procedures Given physical/social distancing is being discussed as a potential way of mitigating the spread of the virus with delaying the peak in the community, it is appropriate to explore alternate ways of interacting with these patients such as telephone or skype or virtual clinics and avoiding hospital visits and postponing elective procedures. The latter approach has already been implemented in many countries including the UK. COVID-19 is known to adhere to the Angiotensin Converting Enzyme 2 (ACE2) receptors7 and thus there are concerns regarding the continued treatment with ACEI/ARBs in patients already taking these drugs. To date we do not know if these medications cause harm in infected patients. Until such evidence emergences, it is prudent to continue cardiovascular therapy as advised by doctors. Cardiovascular Research Studies Whilst efforts during this pandemic should be focussed on treating infected patients needing urgent/emergent medical care, a prudent approach would be to evaluate the essential need for a particular research study in the context of local strain/pressures on resources (staff, logistics and costs etc.,). National authorities (8), (9) already provide some guidance on how to deal with clinical research studies which are reviewed at the institutional level evaluating the pros and cons of ongoing research conduct and any potential modifications to research conduct or suspension of ongoing studies. Worldwide the priority is now to conduct research studies looking at COVID-19. Given the impact of COVID-19 on the cardiovascular system as always as CV healthcare professionals and researchers we will play an important role in this unexpected problem/crisis we are all facing currently.
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