Challenges in cardiac assessment of patients in the COVID-19 era

June 22, 2020 | Melissa Burman, MD, Shoheb Ali, MD

COVID-19, or the corona virus disease of 2019, is caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). COVID-19 is a deadly virus known to cause multisystem collapse, particularly acute and chronic cardiorespiratory complications. The pandemic has placed a silent pressure on institutions, requiring innovative methods for evaluating and treating patients, with an emphasis on reducing the duration of human-human interaction.

A potential complication of COVID-19 is myocarditis, caused by inflammation of the heart muscle due to direct viral injury and/or immune-mediated response, resulting in injury to cardiac tissue. This injury has the potential to recover or result in persistent weakness of the heart.

Acute coronary syndrome (ACS) comprises another range of conditions associated with sudden reduced blood flow to the arteries of the heart, caused by inflammatory-mediated plaque destabilization. Chest pain is a common presentation of ACS, often severe enough to cause most people to present to the emergency department for evaluation.

Due to the various stay at-home protocols, restrictions and barriers to seeking care, and public fear of medical institutions due to COVID-19, many critical conditions are being overlooked by patients until disease progression. Equally concerning, is the observed decline in ACS related hospitalization trends for patients with heart disease and risk factors. Patients, caregivers and health care providers need to be proactive in seeking care for emergent conditions despite the COVID-19 pandemic.

Another challenge faced in the COVID era, relates to the false positives in ACS - mimics of STEMI, a severe type of ACS relating to a complete blockage in one or more arteries supplying blood around the heart. False positives may lead to unnecessary catheterization laboratory procedures, inadvertently leading to increased exposure to clinical staff.

Optimal patient management requires a case by case evaluation of biomarker trends and electrocardiograms (ECG) data within the clinical context. Remote home monitoring solutions will enable clinical decision support systems in mandating who needs urgent invasive assessment vs. non-invasive management with continued monitoring. Due to an unexplained pathophysiology, other cardiac complications of COVID-19 such as life threatening arrhythmias lead to sudden cardiac death, hypercoagulable states that precipitate strokes, and false positive chest pain in intubated patients raise additional concerns. Feasible monitoring with alert notifications can empower clinicians in providing a true patient centric care model while protecting our frontline heroes.

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