Cardiovascular Consequences and Considerations of Coronavirus Infection – Perspectives for the Cardiothoracic Anesthesiologist and Intensivist During the Coronavirus Crisis
2020; Elsevier BV; Volume: 34; Issue: 7 Linguagem: Inglês
10.1053/j.jvca.2020.04.001
ISSN1532-8422
Autores Tópico(s)Climate Change and Health Impacts
ResumoTHE CURRENT pandemic owing to coronavirus disease 2019 (COVID-19) has been associated in about 10% to 15% of cases with severe clinical presentations that require admission to hospital.1Guan WJ, Ni ZY, Hu Y, et al. Clinical characteristics of coronavirus disease 2019 in China. N Engl J Med. https://doi.org/10.1056/NEJMoa2002032, Accessed March 28th 2020. [Epub ahead of print].Google Scholar, 2Huang C.. Wang Y.. Li X.. et al.Clinical features of patients with 2019 novel coronavirus in Wuhan, China.Lancet. 2020; 395: 497-506Abstract Full Text Full Text PDF PubMed Scopus (32423) Google Scholar, 3Yang X, Yu Y, Xu J, et al. Clinical course and outcomes of critically ill patients with SARS-CoV-2 pneumonia in Wuhan, China: A single-centered, retrospective, observational study. Lancet Respir Med. https://doi.org/10.1016/S2213-2600(20)30079-5, Accessed March 29th 2020. [Epub ahead of print].Google Scholar, 4Peng PWH, Ho PL, Hota SS. Outbreak of a new coronavirus: What anaesthetists should know. Brit J Anaesth. https://doi.org/10.1016/j.bja.2020.02.008, Accessed March 30th 2020. [Epub ahead of print].Google Scholar In the cohort of patients with severe COVID-19, the risks of admission to an intensive care unit are high owing to critical conditions such as acute respiratory distress syndrome, cardiovascular collapse, and acute renal failure.1Guan WJ, Ni ZY, Hu Y, et al. Clinical characteristics of coronavirus disease 2019 in China. N Engl J Med. https://doi.org/10.1056/NEJMoa2002032, Accessed March 28th 2020. [Epub ahead of print].Google Scholar, 2Huang C.. Wang Y.. Li X.. et al.Clinical features of patients with 2019 novel coronavirus in Wuhan, China.Lancet. 2020; 395: 497-506Abstract Full Text Full Text PDF PubMed Scopus (32423) Google Scholar, 3Yang X, Yu Y, Xu J, et al. Clinical course and outcomes of critically ill patients with SARS-CoV-2 pneumonia in Wuhan, China: A single-centered, retrospective, observational study. Lancet Respir Med. https://doi.org/10.1016/S2213-2600(20)30079-5, Accessed March 29th 2020. [Epub ahead of print].Google Scholar, 4Peng PWH, Ho PL, Hota SS. Outbreak of a new coronavirus: What anaesthetists should know. Brit J Anaesth. https://doi.org/10.1016/j.bja.2020.02.008, Accessed March 30th 2020. [Epub ahead of print].Google Scholar The unique considerations of this important infection significantly affect the management approaches to these patients by cardiothoracic anesthesiologists and intensivists with respect to airway management, echocardiography, anesthetic care, and extracorporeal membrane oxygenation.5He H, Zhao S, Han L, et al. Anesthetic management of patients undergoing aortic dissection repair with suspected severe acute respiratory syndrome coronavirus-2 infection. J Cardiothorac Vasc Anesth. https://doi.org/10.1053/j.jvca.2020.03.021, Accessed March 29th 2020. [Epub ahead of print].Google Scholar, 6Augoustides JG. Perioperative echocardiography: Key considerations during the coronavirus pandemic. J Cardiothorac Vasc Anesth. https://doi.org/10.1053/j.jvca.2020.03.046, Accessed March 29th 2020. [Epub ahead of print].Google Scholar, 7Pisano A, Landoni G, Zangrillo A. Protecting high-risk cardiac patients during the COVID-19 outbreak. J Cardiothorac Vasc Anesth. https://doi.org/10.1053/j.jvca.2020.03.043, Accessed March 29th 2020. [Epub ahead of print].Google Scholar, 8Augoustides J.G.. Extracorporeal membrane oxygenation – crucial considerations during the coronavirus crisis.J Cardiothorac Vasc Anesth. 2020; 34: 1720-1722Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar, 9The Extracorporeal Life Support Organization. Guidance document: Extracorporeal membrane oxygenation for COVID-19 patients with severe cardiopulmonary failure. Available at: http://covid19.elso.org. Accessed 29 March 2020.Google Scholar, 10Zhao S. Ling K. Yan H. et al.Anesthetic management of patients with suspected or confirmed 2019 novel coronavirus infection during emergency procedure.J Cardiothorac Vasc Anesth. 2020; (Accessed March 30th 2020)https://doi.org/10.1053/j.jvca.2020.02.039Abstract Full Text Full Text PDF Scopus (85) Google Scholar, 11World Health Organization. Clinical management of severe acute respiratory infection when novel coronavirus (2019-nCoV) infection is suspected - interim guidance. Available at: https://www.who.int/publications-detail/clinical-management-of-severe-acute-respiratory-infection-when-novel-coronavirus-(ncov)-infection-is-suspected. Accessed 29 March 2020.Google Scholar The purpose of this freestanding editorial is to highlight the considerations in patients who present with cardiovascular collapse in the setting of severe COVID-19. This clinical perspective will focus on the mechanisms and management of cardiovascular compromise in these challenging patients. The emphasis will relate to the best evidence and consensus in an effort to disseminate the highest standards for care during this crisis. The provided references serve as a guide to further details for healthcare teams as they navigate the cardiovascular demands of the pandemic at their respective institutions. Patients with severe COVID-19 may present with cardiogenic shock.12Driggin E, Madhavan MV, Bikdeli B, et al. Cardiovascular considerations for patients, health care workers, and health systems during the coronavirus disease 2019 (COVID-19) pandemic. J Am Coll Cardiol. https://doi.org/10.1016/j.jacc.2020.03.031, Accessed March 29th 2020. [Epub ahead of print].Google Scholar,13Greenland JR, Michelow MD, Wang L, et al. COVID-19 infection – implications for perioperative and critical care physicians. Anesthesiology. https://doi.org/10.1097/ALN.0000000000003303, Accessed March 29th 2020. [Epub ahead of print].Google Scholar The coronavirus can cause myocarditis and/or pericarditis that may or may not be associated with pneumonia.14Lippi G, Lavie CI, Sanchus-Gomar F. Cardiac troponin 1in patients with coronavirus disease 2019 (COVID-19): Evidence from a meta-analysis. Prog Cardiovasc Dis. https://doi.org/10.1016/j.pcad.2020.03.001, Accessed March 29th 2020. [Epub ahead of print].Google Scholar,15Inciardi R.M. Lupi L. Zaccone G. et al.Cardiac involvement in a patient with coronavirus disease 2019 (COVID-19).JAMA Cardiol. 2020; (Accessed March 29th 2020. [Epub ahead of print])https://doi.org/10.1001/jamacardio.2020.1096Crossref PubMed Scopus (1283) Google Scholar This myocarditis may present clinically with heart failure accompanied by arrhythmias, diffuse ST-segment changes, and significant release of myocardial enzymes, such as natriuretic peptides and troponin.15Inciardi R.M. Lupi L. Zaccone G. et al.Cardiac involvement in a patient with coronavirus disease 2019 (COVID-19).JAMA Cardiol. 2020; (Accessed March 29th 2020. [Epub ahead of print])https://doi.org/10.1001/jamacardio.2020.1096Crossref PubMed Scopus (1283) Google Scholar,16Madjid M, Safavi-Naeini P, Solomon SD, et al. Potential effects of coronaviruses on the cardiovascular system: A review. JAMA Cardiol. https://doi.org/10.1001/jamacardio.2020.1286, Accessed March 29th 2020. [Epub ahead of print].Google Scholar The echocardiographic examination may reveal a diffuse echo-bright myocardial appearance with a pattern of hypokinesis that may or may not have a regional distribution.14Lippi G, Lavie CI, Sanchus-Gomar F. Cardiac troponin 1in patients with coronavirus disease 2019 (COVID-19): Evidence from a meta-analysis. Prog Cardiovasc Dis. https://doi.org/10.1016/j.pcad.2020.03.001, Accessed March 29th 2020. [Epub ahead of print].Google Scholar, 15Inciardi R.M. Lupi L. Zaccone G. et al.Cardiac involvement in a patient with coronavirus disease 2019 (COVID-19).JAMA Cardiol. 2020; (Accessed March 29th 2020. [Epub ahead of print])https://doi.org/10.1001/jamacardio.2020.1096Crossref PubMed Scopus (1283) Google Scholar, 16Madjid M, Safavi-Naeini P, Solomon SD, et al. Potential effects of coronaviruses on the cardiovascular system: A review. JAMA Cardiol. https://doi.org/10.1001/jamacardio.2020.1286, Accessed March 29th 2020. [Epub ahead of print].Google Scholar There may be an associated pericardial effusion with or without clinical tamponade owing to associated pericarditis as part of the COVID-19 spectrum.16Madjid M, Safavi-Naeini P, Solomon SD, et al. Potential effects of coronaviruses on the cardiovascular system: A review. JAMA Cardiol. https://doi.org/10.1001/jamacardio.2020.1286, Accessed March 29th 2020. [Epub ahead of print].Google Scholar,17Olejniczak M, Schwartz M, Webber E., et al. Viral myocarditis – incidence, diagnosis and management. J Cardiothorac Vasc Anesth. https://doi.org/10.1053/j.jvca.2019.12.052, Accessed March 29th 2020. [Epub ahead of print].Google Scholar Specialized imaging with cardiac magnetic resonance and contrast enhancement can detect myocarditis owing to phenomena such as myocardial edema, necrosis, and scar.17Olejniczak M, Schwartz M, Webber E., et al. Viral myocarditis – incidence, diagnosis and management. J Cardiothorac Vasc Anesth. https://doi.org/10.1053/j.jvca.2019.12.052, Accessed March 29th 2020. [Epub ahead of print].Google Scholar, 18Friedrich M.G. Sechtrm U. Schulz-Menger J. et al.Cardiovascular magnetic resonance in myocarditis: A JACC white paper.J Am Coll Cardiol. 2009; 53: 1475-1487Crossref PubMed Scopus (1901) Google Scholar, 19Fung G. Luo H. Qiu Y. et al.Myocarditis.Circ Res. 2016; 118: 496-514Crossref PubMed Scopus (329) Google Scholar In the appropriate clinical setting, these typical features of myocarditis detected by cardiac magnetic resonance may be diagnostic for myocarditis and are frequently equivalent to endomyocardial biopsy.18Friedrich M.G. Sechtrm U. Schulz-Menger J. et al.Cardiovascular magnetic resonance in myocarditis: A JACC white paper.J Am Coll Cardiol. 2009; 53: 1475-1487Crossref PubMed Scopus (1901) Google Scholar,19Fung G. Luo H. Qiu Y. et al.Myocarditis.Circ Res. 2016; 118: 496-514Crossref PubMed Scopus (329) Google Scholar The presentation of myocarditis can result in focal or global myocardial inflammation.17Olejniczak M, Schwartz M, Webber E., et al. Viral myocarditis – incidence, diagnosis and management. J Cardiothorac Vasc Anesth. https://doi.org/10.1053/j.jvca.2019.12.052, Accessed March 29th 2020. [Epub ahead of print].Google Scholar Focal myocarditis may present with acute chest pain and mimic an acute coronary syndrome, resulting in emergency coronary angiography.17Olejniczak M, Schwartz M, Webber E., et al. Viral myocarditis – incidence, diagnosis and management. J Cardiothorac Vasc Anesth. https://doi.org/10.1053/j.jvca.2019.12.052, Accessed March 29th 2020. [Epub ahead of print].Google Scholar,18Friedrich M.G. Sechtrm U. Schulz-Menger J. et al.Cardiovascular magnetic resonance in myocarditis: A JACC white paper.J Am Coll Cardiol. 2009; 53: 1475-1487Crossref PubMed Scopus (1901) Google Scholar There is typically no obstructive coronary artery disease in focal myocarditis.17Olejniczak M, Schwartz M, Webber E., et al. Viral myocarditis – incidence, diagnosis and management. J Cardiothorac Vasc Anesth. https://doi.org/10.1053/j.jvca.2019.12.052, Accessed March 29th 2020. [Epub ahead of print].Google Scholar, 18Friedrich M.G. Sechtrm U. Schulz-Menger J. et al.Cardiovascular magnetic resonance in myocarditis: A JACC white paper.J Am Coll Cardiol. 2009; 53: 1475-1487Crossref PubMed Scopus (1901) Google Scholar, 19Fung G. Luo H. Qiu Y. et al.Myocarditis.Circ Res. 2016; 118: 496-514Crossref PubMed Scopus (329) Google Scholar In patients with COVID-19, there are unique considerations for the catheterization laboratory that have been fully discussed elsewhere.20Welt F.G.P. Shah P.B. Aronow H.D. et al.Catheterization laboratory considerations during the coronavirus-19 (COVID-19) pandemic: From ACC's Interventional Council and SCAI.J Am Coll Cardiol. 2020; Crossref Scopus (329) Google Scholar,21Han Y, Zeng H, Jiang H, et al. CSC expert consensus on principles of clinical management of patients with severe emergent cardiovascular disease during the COVID-19 epidemic. Circulation. https://doi.org/10.1161/CIRCULATIONAHA.120.047011, Accessed March 28th 2020. [Epub ahead of print].Google Scholar The pathogenesis of myocarditis associated with COVID -19 may be owing to direct viral involvement of the myocardium mediated by angiotensin converting enzyme 2.22Clerkin KJ, Fried JA, Raihelkar J, et al. Coronavirus disease 2019 (COVID-19) and cardiovascular disease. Circulation. https://doi.org/10.1161/CIRCULATIONAHA.120.046941, Accessed March 28th 2020. [Epub ahead of print].Google Scholar,23Oudit G.Y. Kassiri Z. Jiang C. et al.SARS –coronavirus modulation of myocardial ACE2 expression and inflammation in patients with SARS.Eur J Clin Invest. 2009; 39: 618-625Crossref PubMed Scopus (657) Google Scholar Further mechanisms include a cytokine storm owing to dysregulated T-helper cells and/or myocardial apoptosis owing to excessive levels of intracellular calcium induced by hypoxia.22Clerkin KJ, Fried JA, Raihelkar J, et al. Coronavirus disease 2019 (COVID-19) and cardiovascular disease. Circulation. https://doi.org/10.1161/CIRCULATIONAHA.120.046941, Accessed March 28th 2020. [Epub ahead of print].Google Scholar Additional research is required to define the relevance of these mechanisms in the pathogenesis of myocarditis associated with COVID-19.22Clerkin KJ, Fried JA, Raihelkar J, et al. Coronavirus disease 2019 (COVID-19) and cardiovascular disease. Circulation. https://doi.org/10.1161/CIRCULATIONAHA.120.046941, Accessed March 28th 2020. [Epub ahead of print].Google Scholar, 23Oudit G.Y. Kassiri Z. Jiang C. et al.SARS –coronavirus modulation of myocardial ACE2 expression and inflammation in patients with SARS.Eur J Clin Invest. 2009; 39: 618-625Crossref PubMed Scopus (657) Google Scholar, 24Zheng YY, Ma YT, Zhong JY, et al. COVID-19 and the cardiovascular system. Nat Rev Cardiol. https://doi.org/10.1038/s41569-020-0360-5, Accessed March 29th 2020. [Epub ahead of print].Google Scholar Patients with severe COVID-19 also may develop vasoplegia and consequent distributive shock.11World Health Organization. Clinical management of severe acute respiratory infection when novel coronavirus (2019-nCoV) infection is suspected - interim guidance. Available at: https://www.who.int/publications-detail/clinical-management-of-severe-acute-respiratory-infection-when-novel-coronavirus-(ncov)-infection-is-suspected. Accessed 29 March 2020.Google Scholar,12Driggin E, Madhavan MV, Bikdeli B, et al. Cardiovascular considerations for patients, health care workers, and health systems during the coronavirus disease 2019 (COVID-19) pandemic. J Am Coll Cardiol. https://doi.org/10.1016/j.jacc.2020.03.031, Accessed March 29th 2020. [Epub ahead of print].Google Scholar This vasoplegic shock may be secondary to sepsis and/or disordered function of the renin-angiotensin-aldosterone system.11World Health Organization. Clinical management of severe acute respiratory infection when novel coronavirus (2019-nCoV) infection is suspected - interim guidance. Available at: https://www.who.int/publications-detail/clinical-management-of-severe-acute-respiratory-infection-when-novel-coronavirus-(ncov)-infection-is-suspected. Accessed 29 March 2020.Google Scholar In patients with severe COVID-19 who require intensive care, the prevalence of septic shock may be about 10% to 15%.25Chow JH, Mazzeffi MA, McCurdy MT. Angiotensin II for the treatment of COVID-19-related vasodilatory shock. Anesth Analg. https://doi.org/10.1213/ANE.0000000000004825, Accessed March 29th 2020. [Epub ahead of print].Google Scholar The management of septic shock in this setting should follow the current guidelines for sepsis, including the recommendations from the World Health Organization.11World Health Organization. Clinical management of severe acute respiratory infection when novel coronavirus (2019-nCoV) infection is suspected - interim guidance. Available at: https://www.who.int/publications-detail/clinical-management-of-severe-acute-respiratory-infection-when-novel-coronavirus-(ncov)-infection-is-suspected. Accessed 29 March 2020.Google Scholar, 12Driggin E, Madhavan MV, Bikdeli B, et al. Cardiovascular considerations for patients, health care workers, and health systems during the coronavirus disease 2019 (COVID-19) pandemic. J Am Coll Cardiol. https://doi.org/10.1016/j.jacc.2020.03.031, Accessed March 29th 2020. [Epub ahead of print].Google Scholar, 13Greenland JR, Michelow MD, Wang L, et al. COVID-19 infection – implications for perioperative and critical care physicians. Anesthesiology. https://doi.org/10.1097/ALN.0000000000003303, Accessed March 29th 2020. [Epub ahead of print].Google Scholar Because pulmonary endothelial damage from adult respiratory distress syndrome is common in severe COVID-19, the function of angiotensin-converting enzyme is disrupted, given that it is located on the pulmonary endothelium.24Zheng YY, Ma YT, Zhong JY, et al. COVID-19 and the cardiovascular system. Nat Rev Cardiol. https://doi.org/10.1038/s41569-020-0360-5, Accessed March 29th 2020. [Epub ahead of print].Google Scholar,25Chow JH, Mazzeffi MA, McCurdy MT. Angiotensin II for the treatment of COVID-19-related vasodilatory shock. Anesth Analg. https://doi.org/10.1213/ANE.0000000000004825, Accessed March 29th 2020. [Epub ahead of print].Google Scholar This loss of functional angiotensin-converting enzyme interferes with the hydrolysis of angiotensin I to form angiotensin II.25Chow JH, Mazzeffi MA, McCurdy MT. Angiotensin II for the treatment of COVID-19-related vasodilatory shock. Anesth Analg. https://doi.org/10.1213/ANE.0000000000004825, Accessed March 29th 2020. [Epub ahead of print].Google Scholar The deficiency of angiotensin II leads to systemic vasodilation. Furthermore, the relative excess of angiotensin I also antagonizes vasoconstriction through multiple mechanisms including enhanced production of systemic vasodilators such as nitric oxide and bradykinin.25Chow JH, Mazzeffi MA, McCurdy MT. Angiotensin II for the treatment of COVID-19-related vasodilatory shock. Anesth Analg. https://doi.org/10.1213/ANE.0000000000004825, Accessed March 29th 2020. [Epub ahead of print].Google Scholar The possibility therefore exists that patients with severe COVID-19 may have vasoplegic shock owing to sepsis and dysregulation of the renin-angiotensin-aldosterone system.25Chow JH, Mazzeffi MA, McCurdy MT. Angiotensin II for the treatment of COVID-19-related vasodilatory shock. Anesth Analg. https://doi.org/10.1213/ANE.0000000000004825, Accessed March 29th 2020. [Epub ahead of print].Google Scholar,26Xiong TY, Redwood S, Prendergast B, et al. Coronaviruses and the cardiovascular system: Acute and long-term implications. Eur Heart J. https://doi.org/10.1093/eurheartj/ehaa231, Accessed March 29th 2020. [Epub ahead of print].Google Scholar Furthermore, the coronavirus requires angiotensin-converting enzyme 2 for cell entry in the lung, leading to possible down-regulation in this part of the renin-angiotensin-aldosterone system.25Chow JH, Mazzeffi MA, McCurdy MT. Angiotensin II for the treatment of COVID-19-related vasodilatory shock. Anesth Analg. https://doi.org/10.1213/ANE.0000000000004825, Accessed March 29th 2020. [Epub ahead of print].Google Scholar,26Xiong TY, Redwood S, Prendergast B, et al. Coronaviruses and the cardiovascular system: Acute and long-term implications. Eur Heart J. https://doi.org/10.1093/eurheartj/ehaa231, Accessed March 29th 2020. [Epub ahead of print].Google Scholar Future trials will explore in detail the effects of this viral process with respect to systemic vascular tone and therapy with inhibitors of the renin-angiotensin-aldosterone system.25Chow JH, Mazzeffi MA, McCurdy MT. Angiotensin II for the treatment of COVID-19-related vasodilatory shock. Anesth Analg. https://doi.org/10.1213/ANE.0000000000004825, Accessed March 29th 2020. [Epub ahead of print].Google Scholar, 26Xiong TY, Redwood S, Prendergast B, et al. Coronaviruses and the cardiovascular system: Acute and long-term implications. Eur Heart J. https://doi.org/10.1093/eurheartj/ehaa231, Accessed March 29th 2020. [Epub ahead of print].Google Scholar, 27Kuster GM, Pfister O, Burkhard T, et al. SARS-CoV2: Should inhibitors of the renin-angiotensin system be withdrawn in patients with COVID-19? Eur Heart J. https://doi.org/10.1093/eurheartj/ehaa235, Accessed March 29th 2020. [Epub ahead of print].Google Scholar There is currently no evidence to suggest that acute coronary arteritis is a clinical feature of COVID-19.11World Health Organization. Clinical management of severe acute respiratory infection when novel coronavirus (2019-nCoV) infection is suspected - interim guidance. Available at: https://www.who.int/publications-detail/clinical-management-of-severe-acute-respiratory-infection-when-novel-coronavirus-(ncov)-infection-is-suspected. Accessed 29 March 2020.Google Scholar,12Driggin E, Madhavan MV, Bikdeli B, et al. Cardiovascular considerations for patients, health care workers, and health systems during the coronavirus disease 2019 (COVID-19) pandemic. J Am Coll Cardiol. https://doi.org/10.1016/j.jacc.2020.03.031, Accessed March 29th 2020. [Epub ahead of print].Google Scholar On the other hand, in older patients with COVID-19, coronary artery disease is likely and may predispose to acute coronary syndromes owing to the increased metabolic stress of severe infection.24Zheng YY, Ma YT, Zhong JY, et al. COVID-19 and the cardiovascular system. Nat Rev Cardiol. https://doi.org/10.1038/s41569-020-0360-5, Accessed March 29th 2020. [Epub ahead of print].Google Scholar, 25Chow JH, Mazzeffi MA, McCurdy MT. Angiotensin II for the treatment of COVID-19-related vasodilatory shock. Anesth Analg. https://doi.org/10.1213/ANE.0000000000004825, Accessed March 29th 2020. [Epub ahead of print].Google Scholar, 26Xiong TY, Redwood S, Prendergast B, et al. Coronaviruses and the cardiovascular system: Acute and long-term implications. Eur Heart J. https://doi.org/10.1093/eurheartj/ehaa231, Accessed March 29th 2020. 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