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COVID-19 and Cardiovascular Disease: Clinical Resources from Penn Medicine

Cardiovascular harm was a noted manifestation of SARS-CoV-2 when the virus appeared in Asia in late 2019.

How does COVID-19 affect the heart?

As of May 2020, we now know that a combination of virus-induced stress factors cause, or contribute to, heart damage. These factors are the typical sequelae of infectious disease: fever and inflammation.

Different elements that seem specific to COVID-19 include a distinct pre-symptomatic phase that includes thrombotic disease, arrhythmias and, rarely, (fulminant) myocarditis.

Anecdotal evidence suggests that the cardiovascular risks of COVID-19 are greatest among patients with pre-existing cardiovascular comorbidities and established heart disease. These patients appear to be predisposed to SARS-CoV-2 infection, and to have more severe disease and worse clinical outcomes.

In the wake of these findings, Penn cardiovascular specialists and cardiac surgeons are part of the national, collaborative and evolving effort to identify and address the cardiovascular risks associated with COVID-19 disease.

Their research is published in the nation’s leading cardiovascular journals.

COVID-19 and the Environment of Cardiovascular Care

COVID-19 and Thromboembolic Disease Management

Writing in the Journal of the American College of Cardiology, an international panel of experts including Penn cardiologist Jay Giri, MD, report on the implications for thromboembolic disease management in the context of COVID-19. The article reviews the current understanding of the pathogenesis, epidemiology, management and outcomes of COVID-19 patients with venous or arterial thrombosis, those with preexisting thrombotic disease who develop COVID-19, or those who need prevention or care for their thrombotic disease during the COVID-19 pandemic.

COVID-19 Cardiovascular Manifestations, Complications and Pathophysiology

In April, a team from Penn Cardiology (including lead author Yuchi Han, MD) provided an overview of the cardiovascular manifestations, complications and pathophysiology of COVID-19 in Heart, the journal of the British Cardiovascular Society. Comprehensive in nature, the article also considers the panoply of treatments for COVID-19, including anticoagulation, ACEI or ARB use, anti-arrhythmic management, immunosuppression/modulation, and hemodynamic support.

Cardiovascular and Cardio-Oncology COVID-19 Trials

The COVID-19 pandemic has resulted in a proliferation of clinical trials designed to slow the spread of SARS-CoV-2. In JACC Cardio-Oncology, the journal’s editor-in-chief Bonnie Ky, MD, of Penn Cardiology, considers these trials to provide a foundation for cardiovascular and cardio-oncology physicians on the front-line providing care to COVID-19 patients, so that they can better understand the emerging cardiovascular epidemiology of COVID-19, and the biological rationale for ongoing clinical trials for the treatment of COVID-19 patients. Dr. Ky is the Director for the Penn Center for Quantitative Echocardiography.

Impact of the COVID-19 Pandemic on Patients With Heart Failure

Nosheen Reza, MD, of Penn Cardiology, co-authored a report in Circulation: Heart Failure, an American Heart Association journal, on preparation for the second wave of challenges ahead for cardiologists beyond the scope of immediate mitigation efforts, and considers the consequences of disruptions in heart failure care at the patient, provider, and systems levels (see Figure 1). Dr. Reza’s co-authors for this report were Drs Ersilia M. DeFilippis, of Columbia University, and Mariel Jessup, Chief Science and Medical Officer of the American Heart Association. Dr Resa is a fellow-in-training in advanced heart failure and transplant cardiology at the Perelman School of Medicine

Guidance and Recommendations for Cardiovascular Care during the COVID-19 Pandemic

Triage Guidelines for Structural Heart Disease Intervention

According to the Centers for Disease Control, sorting out and classifying patients to determine priority of need and proper place of treatment is particularly important during infectious disease outbreaks. To clarify triage for patients referred for structural heart disease interventions during the COVID-19 pandemic, Saif Anwaruddin, MD, of Penn Cardiology took part in composing a consensus statement for the American College of Cardiology and the Society for Cardiovascular Angiography and Intervention. The report appears in Catheterization and Cardiovascular Interventions.

Among much else, the statement offers guidelines for the triage of patients in need of structural heart disease interventions and those in need of trans-catheter aortic valve replacement and percutaneous mitral valve repair, and addresses procedural issues and considerations for the function of structural heart disease teams during the COVID-19 pandemic.

Guidance for the Establishment and Management of ECMO and Other Mechanical Circulatory Support

Writing in the American Heart Association journal Circulation, an international team that included Penn cardiac surgeon Pavan Atluri, MD, has developed a series of algorithms and guidance for the establishment and management of mechanical circulatory support during the COVID-19 pandemic, including extra-corporeal membrane oxygenation (ECMO). Hinging on scenarios with refractory pulmonary and/or myocardial compromise for which ECMO might be appropriate, the authors recommend careful patient selection and the establishment of a priori guidelines and goals of care, and break down ECMO applications for use by comorbidity.

Society of Thoracic Surgeons (STS) COVID-19 Task Force Guidance Statement for Resurgence

Aggressive infection mitigation strategies are a requisite during COVID-19—and this concern was a central tenet of the Society of Thoracic Surgeons COVID-19 Task Force Guidance Statement as public health restrictions are relaxed and non-urgent health care delivery resumes in the months ahead. The multi-institutional Statement, co-authored by Dr. Atluri, appeared in a recent issue of the Annals of Thoracic Surgery. Intended as a framework for the adult cardiac surgeon to consider in the rapidly changing environment of COVID-19, the Statement provides a template for the deliberate and graded delivery of care for adult cardiac surgical programs ramping up as the COVID-19 pandemic burden begins to ease.

STS Guidance on Infection Mitigation in the Surgical Arena

Dr. Atluri was also a co-author for the Society of Thoracic Surgery guidance recommendations on infection control, again in the Annals of Thoracic Surgery.  Far-ranging in detail and recommendations, the STS urges universal precaution against SARS-CoV-2 in the patient population, stressing that all patients be considered COVID-19 suspects regardless of testing availability or results—and outlines pre, intra, and post-operative detailed protective measures and guidance for patients during a pandemic surge and while local COVID-19 disease burdens remain elevated.

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