Multimodality Imaging in Evaluation of Cardiovascular Complications in Patients With COVID-19: JACC Scientific Expert Panel

Abstract

Standard evaluation and management of the patient with suspected or proven cardiovascular complications of coronavirus disease-2019 (COVID-19), the disease caused by severe acute respiratory syndrome related-coronavirus-2 (SARS-CoV-2), is challenging. Routine history, physical examination, laboratory testing, electrocardiography, and plain x-ray imaging may often suffice for such patients, but given overlap between COVID-19 and typical cardiovascular diagnoses such as heart failure and acute myocardial infarction, need frequently arises for advanced imaging techniques to assist in differential diagnosis and management. This document provides guidance in several common scenarios among patients with confirmed or suspected COVID-19 infection and possible cardiovascular involvement, including chest discomfort with electrocardiographic changes, acute hemodynamic instability, newly recognized left ventricular dysfunction, as well as imaging during the subacute/chronic phase of COVID-19. For each, the authors consider the role of biomarker testing to guide imaging decision-making, provide differential diagnostic considerations, and offer general suggestions regarding application of various advanced imaging techniques.

Keywords: COVID-19; myocardial injury; myocarditis; stress cardiomyopathy.

Graphical abstract

Figure 1

Initial Diagnostic Approach The initial diagnostic workup includes history and physical exam, ECG, chest x-ray, and biomarkers. POCUS or a limited echocardiogram should also be considered in selected clinical presentations. ECG = electrocardiogram; POCUS = point of care ultrasound.

Figure 2

Role of Cardiac Imaging in Patients Presenting With Chest Pain and Suspected ACS Patients with chest pain and clinical concern for ST-segment elevation ACS or high clinical risk for in-hospital mortality should be referred for emergent coronary angiography and reperfusion therapy. In patients with equivocal symptoms, atypical or equivocal ECG abnormalities, or late presentation, clinicians may consider POCUS or limited echocardiogram to assess for regional wall motion abnormalities and LVEF and/or coronary CTA to rule out ACS and point to alternate diagnoses discussed of acute cardiac injury. In patients with known CAD and equivocal ECG changes, stress imaging may be helpful. ACS = acute coronary syndrome; CAD = coronary artery disease; cMRI = cardiac magnetic resonance imaging; CTA = computed tomography angiography; CTCA = computed tomography coronary angiography; IC/ED = intensive care/emergency department; LVEF = left ventricular ejection fraction; MI = myocardial infarction; MINOCA = myocardial infarction, normal or nonobstructive coronary arteries; MPI = myocardial perfusion imaging; MRI = magnetic resonance imaging; PCI = percutaneous coronary intervention; PET = positron emission tomography; RWMA = regional wall motion abnormality; TTE = transthoracic echocardiography; other abbreviations as in Figure 1.

Figure 3

Role of Cardiac Imaging in Patients Presenting With Hemodynamic Instability After an initial evaluation, patients with clear STEMI with hemodynamic instability should be referred to coronary angiography and reperfusion therapy without additional imaging. In patients with evidence of significant/worsening myocardial injury, or ECG abnormalities without clear evidence of STEMI, assessment with POCUS or formal echocardiogram is recommended to help exclude pericardial effusion/tamponade, valvular pathology and RV dysfunction. Coronary CTA may be useful to exclude an ACS in patients with equivocal ECG changes and abnormal LV function. Cardiac MRI can help differentiate myocarditis from stress cardiomyopathy and can be considered if it is likely to lead to a change in patient management. CMP = cardiomyopathy; CT = computed tomography; EMB = endomyocardial biopsy; LV = left ventricular; PE = pulmonary embolism; PYP = pyrophosphate; RHC = right heart catheterization; RV = right ventricle; STEMI = ST-segment elevation myocardial infarction; TEE = transesophageal echocardiography; Tn = troponin; other abbreviations as in Figures 1 and 2.

Figure 4

Role of Cardiac Imaging in Patients Presenting With New LVD Without Hemodynamic Instability Acute coronary syndrome should be considered in patients presenting with typical clinical and ECG features and, if present, should be referred to emergent coronary angiography and reperfusion therapy. Distinguishing between acute and chronic LVD in COVID-19 in patients without ACS can be difficult as multiple features overlap. Echocardiography, coronary CTA, CMR, and ischemia testing can be considered depending on initial clinical findings. CMR = cardiac magnetic resonance imaging; LAE = left atrial enlargement; LHC = left heart catheterization; LVD = left ventricular dysfunction; other abbreviations as in Figures 1, 2, and 3.

Central Illustration

Coronavirus Disease-2019 Stages This figure shows the various imaging questions that may present in various stages of coronavirus disease-2019 (COVID-19). The x-axis depicts time. As the disease progress, patient may evolve from having acute disease to a convalescent phase and then chronic disease. The 4 red boxes highlight the various clinical scenarios. The orange boxes list some of the pathological processes that are being evaluated in each scenario. ACS = acute coronary syndrome; CAD = coronary artery disease; CMR = cardiac magnetic resonance imaging; CTA = computed tomography angiography; ECG = electrocardiogram; MRI = magnetic resonance imaging; PET = positron emission tomography; SPECT = single-photon emission computed tomography; STEMI = ST-segment elevation myocardial infarction; VTE = venous thromboembolism.