Cardiovascular Considerations for Patients, Health Care Workers, and Health Systems During the COVID-19 Pandemic

Elissa Driggin, Mahesh V Madhavan, Behnood Bikdeli, Taylor Chuich, Justin Laracy, Giuseppe Biondi-Zoccai, Tyler S Brown, Caroline Der Nigoghossian, David A Zidar, Jennifer Haythe, Daniel Brodie, Joshua A Beckman, Ajay J Kirtane, Gregg W Stone, Harlan M Krumholz, Sahil A Parikh, Elissa Driggin, Mahesh V Madhavan, Behnood Bikdeli, Taylor Chuich, Justin Laracy, Giuseppe Biondi-Zoccai, Tyler S Brown, Caroline Der Nigoghossian, David A Zidar, Jennifer Haythe, Daniel Brodie, Joshua A Beckman, Ajay J Kirtane, Gregg W Stone, Harlan M Krumholz, Sahil A Parikh

Abstract

The coronavirus disease 2019 (COVID-19) is an infectious disease caused by severe acute respiratory syndrome coronavirus 2 that has significant implications for the cardiovascular care of patients. First, those with COVID-19 and pre-existing cardiovascular disease have an increased risk of severe disease and death. Second, infection has been associated with multiple direct and indirect cardiovascular complications including acute myocardial injury, myocarditis, arrhythmias, and venous thromboembolism. Third, therapies under investigation for COVID-19 may have cardiovascular side effects. Fourth, the response to COVID-19 can compromise the rapid triage of non-COVID-19 patients with cardiovascular conditions. Finally, the provision of cardiovascular care may place health care workers in a position of vulnerability as they become hosts or vectors of virus transmission. We hereby review the peer-reviewed and pre-print reports pertaining to cardiovascular considerations related to COVID-19 and highlight gaps in knowledge that require further study pertinent to patients, health care workers, and health systems.

Keywords: cardiovascular therapy; coronavirus; health system.

Copyright © 2020 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

Figures

Graphical abstract
Graphical abstract
Figure 1
Figure 1
Postulated Relationship Between SARS-CoV-2 and ACE2 Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) binds to angiotensin-converting enzyme 2 (ACE2) via spike protein, which facilitates entry into the cell. It is hypothesized that renin-angiotensin-aldosterone system (RAAS) inhibition may up-regulate ACE2 expression, thereby increasing viral entry and replication (top). ACE2 reduces levels of angiotensin II, which is a potent proinflammatory agent in the lungs and can contribute to lung injury. RAAS inhibitors may block the production or function of angiotensin II and potentially also increase levels of ACE2, thereby indirectly inhibiting angiotensin II (bottom).
Figure 2
Figure 2
Risk Factors for Complications and Cardiovascular Sequelae of COVID-19 Risk factors for complications in patients afflicted with coronavirus disease 2019 (COVID-19) and potential cardiovascular issues that may result from this disease process. CVD = cardiovascular disease.
Central Illustration
Central Illustration
Considerations for Patients, Health Care Workers, and Health Systems During the COVID-19 Pandemic Key considerations for patients with established cardiovascular disease (CVD), patients without CVD, and for health care workers and health care systems in the setting of the coronavirus disease 2019 (COVID-19) outbreak. CV = cardiovascular; PPE = personal protective equipment.
Figure 3
Figure 3
Considerations Regarding COVID-19 for Cardiovascular Health Care Workers by Specialty Infographic with important considerations regarding coronavirus disease 2019 (COVID-19) for cardiovascular disease health care workers by specialty. ACLS = advanced cardiac life support; CPR = cardiopulmonary resuscitation; PCI = percutaneous coronary intervention; PPE = personal protective equipment; TEE = transesophageal echocardiography.

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