Acute cardiac injury, variably defined as increased circulating troponin levels and/or new abnormalities on ECG or echocardiography, were noted in 7-22% of hospitalized patients in early reports from Wuhan (Ruan et al; Wang et al; Chen et al; Shi et al; Guo et al, Zhou et al). When present, these findings were associated with increased risk of ICU admission and death.
- Direct SARS-CoV-2 infection of cardiac myocytes (myocarditis)
- Demand ischemia, with either large or small vessel thrombosis
- Stress (Takotsubo) cardiomyopathy
- Pathological myocardial response to inflammation or cytokine storm
Specific cardiac pathologies include myocarditis, arrhythmia, and precipitation of an acute coronary syndrome. Hypercoagulability in COVID-19, including its impact on the heart, are discussed in Hematology.
Fulminant SARS-CoV-2 myocarditis was clinically suspected in some early case reports (Ruan et al; Zeng et al; Hu et al; Inciardi et al), based on pre-existing clinical criteria and, in some cases, suggestive findings on cardiac MRI (Inciardi et al, Kim et al). Subsequent examination of myocardial tissue in autopsy series (Fox et al; Elsoukkary et al; Basso et al) found direct evidence for viral myocarditis (e.g., lymphocytic infiltrates) were relatively rare (0-14%).
The clinical significance of direct SARS-CoV-2 myocarditis remains unclear. If a patient has elevated troponins with no evidence of obstructive coronary artery disease, it may be on the differential diagnosis but is unlikely to alter management.
- Provide supportive care for heart failure (Zhang et al.) or Cardiogenic Shock
- Where possible, discuss with cardiology and/or infectious disease consultants to see if the patient might benefit from antivirals or steroids (benefit is unknown)
- Endomyocardial biopsy is unlikely to be informative.
- See Advanced CV Imaging below regarding uses of cardiac MRI.
Cardiac arrhythmias can occur in COVID-19. An early case series of 138 patients in Wuhan, China, (Wang et al) found evidence of some arrhythmias in 17% of hospitalized patients with COVID-19, rising to 44% in those transferred to the ICU. Another early study of 189 hospitalized patients noted nearly 6% of inpatients had an episode of ventricular fibrillation or sustained ventricular tachycardia (Guo et al).
- Atrial Fibrillation/Atrial Flutter
- Consider beta-blockers, if no evidence of heart failure or shock.
- If acute heart failure or concern for hypotension, use amiodarone if not otherwise contraindicated.
- If unstable (with a pulse), synchronized DC cardioversion with 200 joules (biphasic).
- Ventricular Tachycardia
- If unstable or without