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Guidance on Cardiac Implications of COVID-19 (ACC, 2020)

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MARCH 25, 2020 -- In February 2020, the American College of Cardiology (ACC) released a clinical bulletin to address early cardiac implications of the current novel coronavirus epidemic, COVID-19 (coronavirus disease 2019).[1,2] The guidance is based on case reports as well as “provides information on the potential cardiac implications from analog viral respiratory pandemics and offers early clinical guidance given current COVID-19 uncertainty."

Because “viral infections such as influenza can destabilize and worsen cardiac conditions,” it is likely that COVID-19 will also have an effect, with varying severity in individuals, particularly given indications that 40% of patients with COVID-19 have underlying cardiovascular or cerebrovascular disease.[1,2] These patients are at high risk of having complications and/or dying.

Acute Cardiac Complications of COVID-19

COVID-19-related cardiac complications include arrhythmia and acute cardiac injury.

Conditions that can precipitate cardiac complications include acute-onset heart failure, myocardial infarction, myocarditis, and cardiac arrest, as well as any illness that places a higher cardiometabolic demand on patients.

COVID-19 cardiac complications appear in line with severe acute respiratory syndrome (SARS), Middle East respiratory syndrome (MERS), and influenza analogs.

Cardiologists should prepare to aid other specialists in managing cardiac complications in patients with severe COVID-19.

Cardiology and critical care teams should coordinate management of patients requiring extracorporeal circulatory support with veno-venous (V-V) versus veno-arterial (V-A) extracorporeal membrane oxygenation (ECMO).

Obtain echocardiography in the setting of heart failure, arrhythmia, electrocardiographic (ECG) changes, or cardiomegaly.

ACC Guidance

COVID-19 is a fast-moving epidemic with an uncertain clinical profile; providers should be prepared for guidance to shift as more information becomes available.

COVID-19 is spread through droplets and can live for substantial periods outside the body; containment and prevention using standard public health and personal strategies for preventing the spread of communicable disease remains the priority.

Make plans to quickly identify and isolate cardiovascular patients with COVID-19 symptoms from other patients, including in the ambulatory setting.

Those with underlying cardiovascular disease (CVD) have a higher risk of contracting COVID-19 and have a worse prognosis. Advise these patients of the potential increased risk and encourage additional, reasonable precautions.

It is important for patients with CVD to be up to date with vaccinations, including the pneumococcal vaccine, given the increased risk of secondary bacterial infection; it would also be prudent to receive influenza vaccination to prevent another source of fever which could be initially confused with coronavirus infection.

Older adults are less likely to present with fever, thus close assessment for other symptoms such as cough or shortness of breath is warranted.

In areas with active COVID-19 outbreaks, substituting telephone/telehealth visits for in-person routine visits for stable CVD patients may be reasonable.

The emphasis for CVD patients in areas without widespread COVID-19 should remain on the threat from influenza, the importance of vaccination, and frequent handwashing, and continued adherence to all guideline-directed therapy for underlying chronic conditions.

It is reasonable to triage COVID-19 patients according to the presence of underlying cardiovascular, diabetic, respiratory, renal, oncologic, and other chronic diseases for prioritized treatment.

Providers are cautioned that classic symptoms and presentation of acute myocardial infarction may be overshadowed in the context of coronavirus, resulting in underdiagnosis.

Some experts have suggested that the rigorous use of guideline-directed, plaque-stabilizing agents could offer additional protection to patients with CVD during a widespread outbreak (statins, beta blockers, angiotensin-converting enzyme inhibitors, [ACEIs], acetylsalicylic acid [ASA]); however, such therapies should be tailored to individual patients.

Medscape Medical News



1. Jeffrey S. ACC guidance on cardiac implications of coronavirus. Medscape Medical News. February 13, 2020. Available at: Accessed March 23, 2020.

2.  American College of Cardiology. ACC clinical bulletin: COVID-19 clinical guidance for the cardiovascular care team. Reviewed March 6, 2020. Available at: Accessed March 23, 2020.

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