PMC:7102662 / 14765-18861 JSONTXT

{"target":"https://pubannotation.org/docs/sourcedb/PMC/sourceid/7102662","sourcedb":"PMC","sourceid":"7102662","source_url":"https://www.ncbi.nlm.nih.gov/pmc/7102662","text":"The overall management principles for patients presenting with COVID-19 who develop CV complications or who have pre-existing CVD are same as for any other patient without COVID-19. However, there are a few important points that need consideration-1. As caregivers, it is our utmost responsibility to protect ourselves from getting infected while managing these patients. Therefore, all heathcare personnel engaged in the care of COVID-19 patients must observe necessary precautions at all times. All of them should be trained in donning, usage, and doffing of the personal protective equipment in accordance with the existing practice guidelines.\n2. The hospital systems need to ensure preparedness for dealing with large volume of COVID-19 patients, many of whom would need ICU care and/or acute cardiac care. Appropriate protocols for rapid diagnosis, triage, isolation, and management of COVID-19 patients with CV complications should be developed and well-rehearsed. Rapid triaging and management of these patients is crucial, not only to allow efficient utilization of healthcare resources but also to minimize exposure to caregivers. There are already reports highlighting delays in delivering acute cardiac care due to extra precautions that need to be observed in view of COVID-19 [14]. Efforts should be made to minimize such delays.\n3. Strong emphasis should be placed on avoiding unwarranted diagnostic tests (e.g. cardiac troponin, echocardiography, etc.) in these patients. This is required to minimize unwarranted downstream diagnostic/therapeutic procedures which would further strain the already stretched healthcare resources and would also subject caregivers to added risk of exposure to the infection. The American College of Cardiology has released an advisory discouraging random measurement of cardiac biomarkers such as troponins and natriuretic peptides [15]. It urges all the clinicians to reserve these assays for circumstances in which they would actually meaningfully add to the management of the patients with COVID-19. The American Society of Echocardiography has also issued a similar advisory regarding the use of echocardiography in these patients [16].\n4. The individual hospitals may also have to reconsider risk-benefit ratio of primary percutaneous intervention vs fibrinolysis in patients with COVID-19 who present with ST-segment elevation myocardial infarction.\n5. There has been a concern regarding the safety of ACE inhibitors (ACEi) and angiotensin receptor blockers (ARB) during the ongoing COVID-19 pandemic. These agents upregulate expression of ACE2 in various tissues, including on cardiomyocytes [17]. Since SARS-CoV-2 binds to ACE2 to gain entry into human cells, there is a potentially increased risk of developing COVID-19 or developing more severe disease in patients who are already on background treatment with ACEi/ARB. However, to date, no experimental or clinical data have emerged to support these concerns. At the same time, the risks of discontinuing these therapies are well known. Therefore, several leading professional societies have strongly urged to not discontinue clinically-indicated ACEi/ARB therapy in the event the patient develops COVID-19 [18,19].\n6. Clinicians caring for these patients also need to be fully aware of the potential CV side-effects of various therapies used for treating the viral infection. Additionally, various anti-retroviral drugs have significant interactions with cardiac drugs, which need to be considered and appropriate dose modification done. More recently, chloroquine/hydroxychloroquine and azathioprine have been proposed as potential therapeutic options, based on preliminary evidence [20]. Both these drugs are known to prolong QT interval and due caution must be exercised when prescribing these agents. Their combination is best avoided and even when using chloroquine/hydroxychloroquine alone, daily electrocardiogram for monitoring QT interval is warranted, esp. in patients with hepatic or renal dysfunction and in those receiving another drug with potential to prolong QT 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