ESC guidance for the diagnosis and management of cardiovascular disease during the COVID-19 pandemic: part 2-care pathways, treatment, and follow-up

Abstract

Aims: Since its emergence in early 2020, the novel severe acute respiratory syndrome coronavirus 2 causing coronavirus disease 2019 (COVID-19) has reached pandemic levels, and there have been repeated outbreaks across the globe. The aim of this two part series is to provide practical knowledge and guidance to aid clinicians in the diagnosis and management of cardiovascular (CV) disease in association with COVID-19.

Methods and results: A narrative literature review of the available evidence has been performed, and the resulting information has been organized into two parts. The first, which was reported previously, focused on the epidemiology, pathophysiology, and diagnosis of CV conditions that may be manifest in patients with COVID-19. This second part addresses the topics of: care pathways and triage systems and management and treatment pathways, both of the most commonly encountered CV conditions and of COVID-19; and information that may be considered useful to help patients with CV disease (CVD) to avoid exposure to COVID-19.

Conclusion: This comprehensive review is not a formal guideline but rather a document that provides a summary of current knowledge and guidance to practicing clinicians managing patients with CVD and COVID-19. The recommendations are mainly the result of observations and personal experience from healthcare providers. Therefore, the information provided here may be subject to change with increasing knowledge, evidence from prospective studies, and changes in the pandemic. Likewise, the guidance provided in the document should not interfere with recommendations provided by local and national healthcare authorities.

Keywords: ACE2; Acute coronary syndromes; Arrhythmias; Biomarkers; COVID-19; Cardiogenic shock; Heart failure; Myocarditis; Pulmonary embolism; Thrombosis; Venous thromboembolism.

Graphical Abstract

Figure 1

Management of patients with cardiogenic shock/out-of-hospital cardiac arrest during COVID-19 pandemic. COVID-19, coronavirus disease 2019; ECMO, extracorporeal membrane oxygenation; HCW, healthcare worker; MCS, mechanical circulatory support; SARS-CoV-2, severe acute respiratory syndrome coronavirus 2.

Figure 2

Management of patients with STEMI during COVID-19 pandemic. COVID-19, coronavirus disease 2019; PCI, percutaneous coronary intervention; STEMI, ST-segment elevation MI.

Figure 3

Recommendations for the management of patients with NSTE-ACS in the context of COVID-19 outbreak. CABG, coronary artery bypass graft; COVID-19, coronavirus disease 2019; LVEF, left ventricular ejection fraction; MI, myocardial infarction; NSTEMI, non-ST-segment-elevation MI; PCI, percutaneous coronary intervention; SARS-CoV-2, severe acute respiratory syndrome coronavirus 2. ^aEstimated glomerular filtration rate <60 mL/min/1.73 m². ^bCoronary computed tomography angiography should be favoured, if equipment and expertise are available. In low-risk patients, other non-invasive testing might be favoured in order to shorten hospital stay. It is suggested to perform left ventriculography during catheterization if echocardiography not performed before catheterization laboratory admission.

Figure 4

Hypertension management in the COVID-19 context. ACE, angiotensin-converting enzyme; ARBs, angiotensin II receptor blockers; COVID-19, coronavirus disease 2019.

Figure 5

Atrial tachyarrhythmias. CHA₂DS₂-VASc, congestive heart failure, hypertension, age ≥75 years, diabetes mellitus, stroke, vascular disease, age 65–74 years, sex category (female); COVID-19, coronavirus disease 2019; DC, direct current. ^aThe benefit of intravenous amiodarone treatment should be balanced against the proarrhythmic risk in patients taking QT-prolonging antiviral therapy.

Figure 6

Ventricular tachyarrhythmias. DC, direct current; i.v., intravenous; QT, QT interval; QTc, corrected QT interval; TdP, torsade de pointes; VF, ventricular fibrillation; VT, ventricular tachycardia. ^aThe benefit of i.v. amiodarone treatment should be balanced against the proarrhythmic risk in patients taking QT-prolonging antiviral therapy.

Figure 7

Channelopathies. BrS, Brugada syndrome; COVID-19, coronavirus disease 2019; CPVT, catecholaminergic polymorphic ventricular tachycardia; ECG, electrocardiogram; ICD, implantable cardiac defibrillator. ^aIdeally ECG recordings with V1 and V2 in the fourth, third, and second intercostal spaces.

Figure 8

QTc management. COVID-19, coronavirus disease 2019; ECG, electrocardiogram; LQTS, long QT syndrome; QTc, corrected QC interval. ^aAs long as the patient is clinically stable (e.g. no pronounced vomiting, diarrhoea, signs/symptoms of heart failure or deterioration of respiratory, or other organ function).

Figure 9

Advice for patients from the European Society of Cardiology patient forum.

Figure 10

Telehealth during COVID-19 for people with cardiovascular disease.