Experience With Cardiology-Oriented Outcomes in Critically Ill Patients With Coronavirus Disease 2019

Abstract

Objectives: Coronavirus disease 2019 is associated with high mortality rates and multiple organ damage. There is increasing evidence that these patients are at risk for various cardiovascular insults; however, there are currently no guidelines for the diagnosis and management of such cardiovascular complications in patients with coronavirus disease 2019. We share data and recommendations from a multidisciplinary team to highlight our institution's clinical experiences and guidelines for managing cardiovascular complications of coronavirus disease 2019.

Design setting and patients: This was a retrospective cohort study of patients admitted to one of six ICUs dedicated to the care of patients with coronavirus disease 2019 located in three hospitals within one academic medical center in Atlanta, Georgia.

Measurements/interventions: Chart review was conducted for sociodemographic, laboratory, and clinical data. Rates of specific cardiovascular complications were assessed, and data were analyzed using a chi-square or Wilcoxon rank-sum test for categorical and continuous variables. Additionally, certain cases are presented to demonstrate the sub committee's recommendations.

Main results: Two-hundred eighty-eight patients were admitted to the ICU with coronavirus disease 2019. Of these, 86 died (29.9%), 242 (84.03%) had troponin elevation, 70 (24.31%) had dysrhythmias, four (1.39%) had ST-elevation myocardial infarction, eight (2.78%) developed cor pulmonale, and 190 (65.97%) with shock. There was increased mortality risk in patients with greater degrees of troponin elevation (p < 0.001) and with the development of arrhythmias (p < 0.001), cor pulmonale (p < 0.001), and shock (p < 0.001).

Conclusions: While there are guidelines for the diagnosis and management of pulmonary complications of coronavirus disease 2019, there needs to be more information regarding the management of cardiovascular complications as well. These recommendations garnered from the coronavirus disease 2019 cardiology subcommittee from our institution will add to the existing knowledge of these potential cardiovascular insults as well as highlight suggestions for the diagnosis and management of the range of cardiovascular complications of coronavirus disease 2019. Additionally, with the spread of coronavirus disease 2019, our case-based recommendations provide a bedside resource for providers newly caring for patients with coronavirus disease 2019.

Keywords: arrhythmia; cor pulmonale; coronavirus disease 2019; myocardial ischemia; myocarditis; shock.

Figure 1.

Coronavirus Disease 2019 (COVID-19) Cardiac Guideline Recommendations phone card reference. ATIII = antithrombin III, C3/C4 = complement levels 3 and 4, CCB = calcium channel blocker, CRP = C-reactive protein, DHP = dihydropyridine, ECG = electrocardiogram, ECHO = echocardiography, ECMO = extracorporeal membrane oxygenation, ESR = erythrocyte sedimentation rate, HF = heart failure, H&P = history and physical, IABP = intra-aortic balloon pump, IJ = internal jugular, IL-6 = interleukin 6, LDH = lactate dehydrogenase, LV = left ventricle, LVAD = left ventricular assist device, PEEP = positive end-expiratory pressure, POCUS = point of care ultrasound, RV = right ventricle, STEMI = ST-elevation myocardial infarction, PCI = percutaneous coronary intervention, QT = QT interval, QTc = corrected QT interval, SvO₂ = mixed venous oxygen saturation.

Figure 2.

Electrocardiogram 2 wk later with ongoing T wave inversion in the precordial leads. aVF = augmented vector foot, aVL = augmented vector left, aVR = augmented vector right.

Figure 3.

Electrocardiogram demonstrating diffuse ST elevation. aVF = augmented vector foot, aVL = augmented vector left, aVR = augmented vector right.