The Heart and COVID-19: What Cardiologists Need to Know

Isabela Bispo Santos da Silva Costa, Cristina Salvadori Bittar, Stephanie Itala Rizk, Antônio Everaldo de Araújo Filho, Karen Alcântara Queiroz Santos, Theuran Inahja Vicente Machado, Fernanda Thereza de Almeida Andrade, Thalita Barbosa González, Andrea Nataly Galarza Arévalo, Juliano Pinheiro de Almeida, Fernando Bacal, Gláucia Maria Moraes de Oliveira, Marcus Vinícius Guimarães de Lacerda, Silvio Henrique Barberato, Antonio Carlos Palandri Chagas, Carlos Eduardo Rochitte, José Antonio Franchini Ramires, Roberto Kalil Filho, Ludhmila Abrahão Hajjar, Isabela Bispo Santos da Silva Costa, Cristina Salvadori Bittar, Stephanie Itala Rizk, Antônio Everaldo de Araújo Filho, Karen Alcântara Queiroz Santos, Theuran Inahja Vicente Machado, Fernanda Thereza de Almeida Andrade, Thalita Barbosa González, Andrea Nataly Galarza Arévalo, Juliano Pinheiro de Almeida, Fernando Bacal, Gláucia Maria Moraes de Oliveira, Marcus Vinícius Guimarães de Lacerda, Silvio Henrique Barberato, Antonio Carlos Palandri Chagas, Carlos Eduardo Rochitte, José Antonio Franchini Ramires, Roberto Kalil Filho, Ludhmila Abrahão Hajjar

Abstract

In face of the pandemic of the novel coronavirus disease 2019 (COVID-19), the management of patients with cardiovascular risk factors and/or disease is challenging. The cardiovascular complications evidenced in patients with COVID-19 derive from several mechanisms, ranging from direct viral injury to complications secondary to the inflammatory and thrombotic responses to the infection. The proper care of patients with COVID-19 requires special attention to the cardiovascular system aimed at better outcomes.

Conflict of interest statement

Potencial conflito de interesses

Declaro não haver conflito de interesses pertinentes.

Figures

Figura 1. Coronavírus e o Coração. Os…
Figura 1. Coronavírus e o Coração. Os pacientes com fatores de risco e/ou doença cardiovascular são mais propensos a desenvolver formas graves e complicações relacionadas a COVID-19. O quadro pulmonar manifesta-se inicialmente por síndrome gripal (com tosse e febre), evolui para pneumonia (dispneia, hipoxemia, taquipneia) e, em alguns casos, para síndrome do desconforto respiratório agudo. A resposta do organismo ao vírus leva a um quadro de inflamação sistêmica, na qual se observa elevação de marcadores inflamatórios (PCR, procalcitonina, dímero-d, IL-6, ferritina, DHL) e de injúria miocárdica / disfunção cardíaca (troponina/NT-proBNP), que predispõe a insuficiência cardíaca aguda, miocardite, trombose e arritmias. As complicações cardiovasculares pioram a resposta do organismo ao vírus, levando a choque, falência de múltiplos órgãos e morte.
AVC: acidente vascular cerebral; DAC: doença arterial coronária; DHL: desidrogenase láctica; FEVE: fração de ejeção do ventrículo esquerdo; PCR: proteína C reativa; IL-6: interleucina-6; SDRA: síndrome do desconforto respiratório agudo.
Figura 2. O SARS-CoV-2 liga-se por meio…
Figura 2. O SARS-CoV-2 liga-se por meio da proteína spike da superfície viral ao receptor da ECA2 humana após a ativação da proteína spike pela TMPRSS2.SARS-CoV: Coronavírus da síndrome respiratória aguda grave; SARS-COV-2: Coronavírus da síndrome respiratória aguda grave 2; COVID-19: doença do coronavírus 2019; ECA2,:enzima conversora de angiotensina-2; TMPRSS2: serina protease transmembrana-2.
Figura 3. Fluxograma proposto para avaliação cardíaca…
Figura 3. Fluxograma proposto para avaliação cardíaca do paciente com suspeita de COVID-19. *Idade avançada, doença arterial coronária, doença cerebrovascular, hipertensão arterial, diabetes mellitus, cardiomiopatia ou portador de arritmia. COVID-19: doença do Coronavírus 2019; DCV: doença cardiovascular; ECG +: taquicardia supraventricular ou ventricular, alterações de repolarização novas sugestivas de isquemia aguda; ECG -: eletrocardiograma sem alterações agudas; ECO: ecocardiograma; mod: moderados; Tropo +: níveis de troponina maior que o percentil 99 do valor de referência; Tropo -: níveis de troponina abaixo do percentil 99; UTI: Unidade de Terapia Intensiva.
Figura 4. Ressuscitação cardiopulmonar em paciente com…
Figura 4. Ressuscitação cardiopulmonar em paciente com COVID-19. PCR: parada cardiorrespiratória; COVID-19: doença do Coronavírus 2019; EPI: equipamento de proteção individual; ACLS: Advanced Cardiovascular Life Support.
Figure 1. Coronavirus and the heart. Patients…
Figure 1. Coronavirus and the heart. Patients with risk factors and/or cardiovascular disease are prone to develop severe forms of COVID-19 and its complications. Pulmonary impairment manifests initially as an influenza syndrome (cough and fever), progressing to pneumonia (dyspnea, hypoxemia, tachypnea) and, in some cases, to ARDS. Host response to the virus leads to systemic inflammation findings, with elevation of markers of inflammation (CRP, procalcitonin, d-dimer, IL-6, ferritin, LDH) and of myocardial injury / cardiac dysfunction (troponin/NT-proBNP), which predisposes to acute heart failure, myocarditis, thrombosis and arrhythmias. Cardiovascular complications hinder the host response to the virus, leading to shock, failure of multiple organs and death.
CAD: coronary artery disease; LDH: lactate dehydrogenase; LVEF: left ventricular ejection fraction; CRP: C-reactive protein; IL-6: interleukin-6; ARDS: acute respiratory distress syndrome.
Figure 2. The SARS-CoV-2, via its surface…
Figure 2. The SARS-CoV-2, via its surface spike protein, binds to the human ACE2 receptor after spike protein activation by TMPRSS2. SARS-CoV: severe acute respiratory syndrome coronavirus; SARS-COV-2: severe acute respiratory syndrome coronavirus 2; COVID-19: coronavirus disease 2019; ACE2: angiotensin-converting enzyme-2; TMPRSS2: transmembrane protease serine-2.
Figure 3. Flowchart for cardiac assessment of…
Figure 3. Flowchart for cardiac assessment of patients with suspected COVID-19. *Advanced age, coronary artery disease, cerebrovascular disease, arterial hypertension, diabetes mellitus, cardiomyopathy or arrhythmia. COVID-19: Coronavirus disease 2019; CVD: cardiovascular disease; ECG +: supraventricular or ventricular tachycardia, new repolarization changes suggestive of acute ischemia; ECG -: electrocardiogram without acute changes; ECHO: echocardiogram; mod: moderate; Tropo +: troponin levels above the 99th-percentile upper reference limit; Tropo -: troponin levels below the 99th-percentile; ICU: intensive care unit.
Figure 4. Cardiopulmonary resuscitation of patients with…
Figure 4. Cardiopulmonary resuscitation of patients with COVID-19. CRA: cardiorespiratory arrest; COVID-19: Coronavirus disease 2019; PPE: personal protective equipment; ACLS: Advanced Cardiovascular Life Support; FiO2:fraction of inspired oxygen; RR: respiratory rate.

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