Public health

COVID-19 to be balanced with cardiac care: Australian consensus statement

A consensus statement on cardiovascular disease and COVID-19 has highlighted some of the many considerations for patients known to be at high risk during the pandemic.

Developed by experts from the CSANZ, ANZ Society of Cardiac and Thoracic Surgeons, National Heart Foundation and the High Blood Pressure Research Council of Australia, the statement said patients with CVD had a 5-10 fold higher risk of death than other people with COVID-19.

It said the case fatality rate for CVD patients (10.5%) was higher than patients with diabetes (7.3%), chronic respiratory disease (6.3%), cancer (5.6%) or people with no known comorbidities (0.9%).

The statement said acute cardiac injury in COVID-19 manifests as left ventricular dysfunction, heart failure, ventricular arrhythmias, ECG changes and elevated troponin and BNP levels.

However the diagnostic implications of the elevated biomarkers were unclear.

Lead author Associate Professor Sarah Zaman, from Monash Heart, told the limbic it was still important to do the troponin tests because they were a prognostic indicator.

“We’re not saying don’t do the test just because it is invariably going to be high in a lot of hospitalized patients with COVID-19. But at the same time, you can’t do a troponin and call it a heart track. It makes decision-making a bit more nuanced and you’ve got to make a differential for the high troponin e.g. myocarditis or even acute respiratory failure.”

The statement said haemodynamically stable patients with COVID-19 and possible MI may be best managed conservatively, with invasive procedures deferred until after COVID-19 recovery.

It also said some cardiac investigations pose a significant risk of viral transmission. For example, transesophageal echo (TOE) should only be performed after exclusion of COVID-19 or as a last resort and then with full precautions.

The statement said clinicians should be alert to cardiac toxicity, specifically long QT and Torsades des Pointes, from some therapies used in COVID-19 including chloroquine, hydroxychloroquine and azithromycin.

The authors said delays were to be expected with primary PCI to allow for COVID-19 assessment and infection control measures.

“Training in PPE, sourcing fibrinolytic medications and updating lysis protocols are critical. As COVID-19 is associated with STEMI ‘mimickers’ (ST elevation without obstructive CAD due to microvascular thrombosis or myocarditis), use of lysis may confer risk without benefit in some cases, exacerbated by COVID-associated coagulation abnormalities.”

They noted that despite the resourcing demands that COVID-19 will place on healthcare systems, it might be important to continue to provide STEMI services for non-COVID-19 rural and regional patients who were already at a disadvantage in terms of cardiovascular outcomes.

Associate Professor Zaman said care had to be taken not to refuse any patient who had come to hospital just because of the risk of coronavirus.

“We don’t want to sacrifice good quality cardiac care just because we want to avoid any potential for exposure in our patients. You can swing from one extreme to the other and both can have detrimental impacts,” she said.

“At the moment, our healthcare system hasn’t become overwhelmed so we are not facing the same crisis as in the UK and the US. We have certainly slowed down that progression and if it stays that way, we will cope.”

The statement said the COVID-19 pandemic meant cardiac surgical cases were likely to take longer due to infection control measures and access to ICU would be limited.

“COVID-free patients recovering from cardiac surgery in ICU require separation from suspected or proven COVID-19 ICU patients. Establishing or re-establishing Cardiac Surgical ICU programs could be possible and free-up precious general ICU resources.”

The authors concluded that COVID-19 will have a significant and lasting impact on cardiology practice in Australia and New Zealand.

“The preparation and adaptability of the cardiac team will be critical to respond to this global COVID-19 crisis.”

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