A cardiologists perspective to current scenario in light of corona pandemic in india and world wide. cardiac procedures , heart disease , aceinhibitors , arni , heart failure , troponin, nt probnp

1. DR ASHWANI MEHTA
SIR GANGA RAM HOSPITAL
COVID- 19 , A Cardiologist’s
Perspective

2. • Introduction to corona virus
• Impact of corona Virus on Cardiologist
• Impact of Corona Virus on patients
• Safety of Doctors
• Guidelines and Position statement
• Treating Patients in the OPD
• How Corona infection can mimic ACS
• Treating Patients with ACS in times of COVID /Interventions in present times
• Should ARBs and ACEI be stopped
• Use of Asprin and NSAIDs
• Use of Anti coagulation in patients suffering from Cardiac manifestations
• Drugs for treatment of Corona , where do we stand
A Brief Overview

3. EFFECT OF COVID PANDEMIC ON
HEALTHCARE
• COVID-19 has dramatically altered our world, health care systems and supply chains.
• Older adults with cardiovascular disease especially those over 60 years suffer
disproportionately.
• Stressed the capacity of the hospital infrastructure, ICU beds and ventilatory support, post-
acute and community care resources, hospital personnel and personal protection equipment.
• Change in the way we practice medicine and also the treatment protocols have been modified
• Risk stratification based on clinical and laboratory data may assist in the process of
prognostication and shared decision-making

4. DRY COUGH (76%)HIGH FEVER (98%)
Irritation and constant
coughing without expelling
any mucus
The body feels completely
tired and without energy to
perform normal tasks
The body temperature can
exceed 37.3 Celsius degrees
or 99 Fahrenheit degrees
SYMPTOMS OF COVID-19
TIREDNESS (44%)
Other: Sputum production (28%) and Diarrhoea (3%)

5. More than half of the patients developed shortness of breath roughly eight days
from the onset of illness

6. Clinical Features
• Mild: no symptoms, mild caughing and fever.
• Severe: dyspnea, hypoxia or > 50% lung involvement on imaging.
• Critical: respiratory failure, shock, multi-organ failure. A PATIENT WHO IS IN
EMINENT DANGER
A PATIENT WHO IS IN EMINENT DANGER
• Difficulty breathing or shortness of breath
• Persistent pain or pressure in the chest
• New confusion or inability to arouse
• Bluish lips or face
• Low Oxygen Saturation

7. PCR-test
• Very specific
• Lower sensitivity of 65-95%, which means that the test can be
negative even when the patient is infected.
• Waiting time 24 hours, while CT results are available right away.
• Common laboratory findings in COVID-19 are a decreased lymphocyte
count and an increased CRP and high-sensitivity C-reactive
protein level.

8. In Severe COVID-19 patients
Laboratory Markers In COVID-19 Patients

9. X Ray Features
1. Picture not like lobar pneumonia- Bilateral , mimics Viral pneumonia
2. Poorly demarcated , bilateral , peripheral consolidation
3. Uncommon to have pleural effusion. which is late
4. May mimic features of volume overload
CT Scan Features – more specific
1. GROUND GLASSING and peripheral areas of consolidation , but nit well demarcated as
lobar pneumonia
2. No lymphadenopathy
Radiological features of corona infection

10. CT findings - hallmark
• Ground glass pattern is the most common finding in COVID-19 infections.
They are usually multifocal, bilateral and peripheral, but in the early may present
as a unifocal lesion, most commonly in inferior lobe of the right lung
• Other are – Crazy paving , Vascular dilatation , Traction bronchiectasis , Sub
pleural bands and architecture

11. • COVID-19 might enter the human body via angiotensin-converting enzyme 2 (ACE2)
on the surfaces of type II alveolar cells.
• ↓
• The virus may exhibit pathogenic activity by attacking type II alveolar epithelial cells
expressing ACE2.
• ↓
• ACE2 is likely to be the cellular receptor of COVID-19, but whether it is the only
cellular receptor remains to be further investigated
Interplay between SARS-CoV-2 and ACE2 receptor
Hypertension Research. 2020. March 3:1-3

12. Interplay between SARS-CoV-2 and ACE2 receptor

13. Am J Physiol Endocrinol Metab. 2020 Mar 31. doi: 10.1152/ajpendo.00124.2020.

15. SAVE THE PROTECTORS
PROTECTION OF THE HEALTH CARE PROFESSIONALS

16. • Physician should wear white coats, paper
caps and surgical masks (PPE)
• High Risk and more than 60 should avoid
• Strictly perform hand hygiene in
outpatient clinic (before/after patient
contact)
• Avoid use of stethoscope
Physician in OPD

17. Personal Protection Equipment
• Integrated protective clothing
• Goggles (protective face screen or
protective hood)
• Infrared thermometer
• N95 masks
• Disposable shoe covers (long style
recommended)
• Sterile instrument sets
• Air sterilizers
• Disposable sheets, etc.

18. a) Give suspect patient a triple layer surgical mask and
b) Direct patient to separate area, an isolation room if available.
c) Keep at least 1meter distance between suspected patients and other
patients.
d) Instruct all patients to cover nose and mouth during coughing or sneezing
with tissue or flexed elbow for others.
e) Perform hand hygiene after contact with respiratory secretions.
At Triage: In Hospital

19. a) Droplet precautions prevent large droplet transmission of respiratory viruses.
b) Use a triple layer surgical mask if working within 1-2 metres of the patient.
c) Place patients in single rooms, or group together those with the same etiological
diagnosis.
d) If possible, use either disposable or dedicated equipment (e.g. stethoscopes, blood
pressure cuffs and thermometers).
e) If equipment needs to be shared among patients, clean and disinfect between each
patient use.
f) Avoid contaminating environmental surfaces that are not directly related to patient
care (e.g. door handles and light switches).
g) Ensure adequate room ventilation.
Apply droplet precautions all through the care:

20. TREATMENT

21. Management strategy of COVID-19 combined with CVD
• Induce COVID-19 infection
• Avoid acute cardiac events
（heart failure,ACS）
• Potential proarrhythmia
• Vasoactive agent induced acute
events such as vasospasm
• Drug interaction induced liver
injury
• ECG、BP monitoring
• Early intervention
•Diagnosis of COVID-19
in time
•Respiratory support： rectifying
hypoxia
•Circulation support：maintain
volume balance
•Immunotherapy
Early self-
management
Diagnosis
in time
drug
interactions
Therapy
for severe
cases

22. Common Co-morbid conditions with COVID-19
other than age alone
Hypertension 23.7%
Diabetes mellitus 16.2%
Coronary heart diseases 5.8%
Cerebrovascular disease 2.3 %
N Engl J Med 2020; published online Feb 28. DOI:10.1056/NEJMoa2002032.

23. Association of hypertension with COVID-19 mortality
Pol Arch Intern Med. 2020 Mar 31. doi: 10.20452/pamw.15272.

24. Hypertension comprised 20–30% of all COVID-19 patients
58.3% of hypertensive patients in the intensive care unit due to COVID-19.
Hypertension have been responsible for 60.9% of deaths caused by COVID-19.
Hypertension may be associated with an up to 2.5-fold higher risk of severe
and fatal COVID-19, especially among older individuals.
Hypertension should be considered as a clinical predictor of COVID-19 severity
in older patients
Hypertension–COVID-19 Link
Hypertension Research. 2020. March 3:1-3
Pol Arch Intern Med. 2020 Mar 31. doi: 10.20452/pamw.15272.

25. 1. People with diabetes are more likely to experience severe symptoms and
complications when infected with a virus
2. If diabetes is well-managed, the risk of getting severely sick from COVID-19 is
about the same as the general population
3. Having heart disease or other complications in addition to diabetes could worsen
the chance of getting seriously ill from COVID-19
4. If glucose control is poor, severity of viral illness and risk of complications will
increase because of impairment of immunity.
5. People with diabetes do face an increased risk of DKA (diabetic ketoacidosis) and
or Hypoglycemia, Specialy pts with type 1 diabetes.
COVID-19 and Diabetic patients

26. People with diabetes do face a
higher chance of experiencing
serious complications from
COVID-19

27. • Patients with diabetes, particularly those with poor glycaemic control, as they
are at increased risk of complications, they should be instructed about
warning symptoms and need for hospitalization if they develop such
symptoms.
• Always to be in touch with your personal doctor in such situations
Precautions to be taken in diabetics:

29. HCQS – NO CLEAR EVIDENCE???

30. Symptomatic treatment
• Supportive Treatment- anti tussevies,paracetamol,Hydration
• Oxygen supplementation to maintain SpO2>94Conservative fluid management if
there is no evidence of shock.
• Tab Hydroxychloroquine, 400mgBD for1dayfollowedby200mgBDfor4days
• Tab Azithromycin,500 OD for 5 days
• Tab Oseltamivir,150 mg BD for 5 days
• Tab Vitamin C,500mgBDfor5days
• If Hydroxychloroquine or,Chloroquine contraindicated
• then:Lopinavir/Ritonavir(200/50) 2 tab BD for 10 days
• Caution: Do not co-administer Lopinavir/ritonavir and Hydroxychloroquine
(eg.QTprolongation,hypoglycemia).

31. How HCQS works
• Not clearly
known, changes
the pH of
endosomes and
believed to
prevents viral
entry, transport
and post-entry
event

32. HCQS where do we stand ?

33. The National Taskforce for COVID-19 recommends
,ICMR -use of hydroxy-chloroquine for prophylaxis
of SARS-CoV-2
• Asymptomatic healthcare workers involved in the care of suspected or
confirmed cases of COVID-19
• Asymptomatic household contacts of laboratory confirmed cases
• Dose for HCW:400 mg twice a day on Day 1, followed by 400 mg once
weekly for next 7 weeks; to be taken with meals.
• Dose for Asymptomatic household contacts of laboratory confirmed cases:
400 mg twice a day on Day 1, followed by 400 mg once weekly for next 3
weeks; to be taken with meals .
• Note - It is reiterated that the intake of above medicine should not in still sense of
false secuirity. The hydroxy-chloroquine may not be replaced by any other
compound.

34. DRUG TREATMENT:
Other drugs which are being tested on an experimental basis
and are not available in India as of now.
Remdesivir -Several randomized trials , used for Ebola
Favipiravir- Japanese molecule
Kaletra- Anti HIV drug
Tocilizumab – Treatment guidelines from China's National
Health Commission include the IL-6 inhibitor tocilizumab for
patients with severe COVID-19 and elevated IL-6 levels
Ivermectin

35. Cardiac Symptoms in patients with Covid
infections – ACS or COVID Infection?

36. • Interactions between antiviral drugs and cardiovascular drugs: Lopinavir and
Ritonavir may increase the liver injury and cause the elevation of muscle
enzyme if taken with some kinds of statins at the same time.
• Be alert to the direct or indirect damaging effects of antiviral drugs on heart:
Chloroquine may induce sudden cardiac death, while Lopinavir and Ritonavir
may lower the heart rate
• HCQS and Cholroquin can prolong the QT interval
Potential interactions between antiviral drugs and
cardiovascular drugs
Yundai Chen. Chinese Journal of Interventional Cardiology; 2020; 28(2):107-109

37. CARDIAC MANIFESTATIONS

38. How covid effects heart
• In addition to lung damage, many COVID-19 patients are also
developing heart problems—and dying of cardiac arrest.
• As more data comes in from China and Italy, as well as Washington
state and New York, more cardiac experts are coming to believe the
COVID-19 virus can infect the heart muscle.
• An initial study found cardiac damage in as many as 1 in 5 patients,
leading to heart failure and death even among those who show no
signs of respiratory distress

39. Acute Cardiac Complications of COVID-19
• Anecdotal reports of acute heart failure, myocardial infarction,
myocarditis, and cardiac arrest; as with any acute illness, higher
cardiometabolic demand can precipitate cardiac complications
• Raised Cardiac enzymes – troponin I suggesting Cardiac injury
• Some patients also have myocarditis with global LV Hypokinesia , some
patients have RWMA also.
• Ecg changes also seen mimicking Acute MI and NSTEMI.
• Chest Xray , ECG, CT Chest , Cardiac Enzymes and Echocardiography etcare
required .
• Some patients develop arrhythmias , which may be worsened by HCQS etc.

40. Acute Cardiac Complications of COVID-19
• In a recent case report on 138 hospitalized COVID-19 patients,
16.7% of patients developed arrhythmia and 7.2% experienced
acute cardiac injury.
• Cardiologists should be prepared to assist other clinical specialties in
managing cardiac complications in severe cases of COVID-19
• Critical care and cardiology teams should confer to guide care for
patients requiring extracorporeal circulatory support with veno-
venous (V-V) versus veno-arterial (V-A) ECMO
• Patients demonstrating heart failure, arrhythmia, ECG changes or
cardiomegaly should have echocardiography

41. COVID-19 Implications For Patients With
Underlying Cardiovascular Conditions
• Make plans for quickly identifying and isolating cardiovascular
patients with COVID19 symptoms
• Patients with underlying cardiovascular disease are at higher risk of
contracting COVID-19 and have a worse prognosis
• CVD pts to remain current with vaccinations, including the
pneumococcal and influenza.
• Triage COVID-19 patients according to underlying cardiovascular,
diabetic, respiratory, renal, oncological, or other comorbid conditions
for prioritized treatment.

42. Cardiac-specific Preparedness Recommendations
For COVID-19 –General guidelines
• Protocols for the diagnosis, triage, isolation, and management of COVID-19
patients with cardiovascular complications and/or cardiovascular patients
with COVID-19 should be developed in detail and rehearsed.
•
Cardiovascular care team members protective equipment (PPE) donning,
usage, and doffing should be trained now in accordance with CDC guidance
• Specific protocols should be developed for the management of AMI in the
context of a COVID-19 outbreak, both for patients with and without a
COVID-19 diagnosis
• Particular emphasis should be placed on acute PCI and CABG, including
protocols to limit catheterization lab and OR personnel to a required
minimum.

43. How Covid infections mimic Cardiac Symptoms

44. Management of ACS incl. AMI in times of
Corona- key points
• For AMI patients with COVID-19, a safe and efficient medical
environment should be ensured in parallel with effective reperfusion
therapy.
• Many medical centers do not have professionally protected cardiac
catheterization rooms and cardiac care units for respiratory infectious
diseases.
• Coordination of hospital administrators and the collaboration of
multidisciplinary teams including the cardiology , emergency ,
respiratory , radiology and the medical laboratory .
• Emergency intravenous thrombolysis is the first choice for acute ST-
segment elevation myocardial infarction (STEMI).

45. Thrombolysis in patient with unknown risk

46. STEMI patients with confirmed COVID-19
• Strict isolation should start immediately, and thrombolytic
contraindications should be evaluated. Patients with thrombolytic
contraindications should be transferred to the local designated COVID
treatment.
• Patients without thrombolytic contraindications should first start
intravenous thrombolysis and then transfer to the local designated
medical institution of infectious disease for further treatment

47. Patient with acute Micame at 4 00Am on
13/04/2020

48. After thrombolysis with TPA

49. AMI with non-STEMI (NSTEMI),
• For treatment strategy should be based on the GRACE risk stratification
while waiting for the results of novel coronavirus nucleic acid detection.
• Confirmed patients with COVID-19 should be transferred to the designated
medical institution immediately for further optimal medical treatment.
• If COVID-19 cannot be excluded by chest CT, routine medical treatment of
NSTEMI should be given and risk stratification should be conducted while
waiting for the results of nucleic acid detection.
• For NSTEMI patients excluded from COVID-19, early or time-limited
intervention strategies as per risk stratification of NSTE–acute coronary
syndrome.

50. Are we getting all ACS patients?

51. Non Coronary Interventions during present
times
• Avoid all non essential Interventions – EP procedures ,
Radiofrerquency abalation , balloon valvotomies ,etc
• Pacemakers implants are usually emergency procedures, which have
to be done with precautions .

53. Cardiac Drug options for patients with COVID-19
combined with CVD
• ACEI/ARB: Patients should continue taking these medication
• Antiplatelet drugs：For CVD patients, continue taking the same medication, and
hemorrhage should be observed strictly.
• Nsaids- Data equivocal , no clear harm or benefit , some data from Italy suggested
harm from ibuprofen , but not proven .
• Statins：monitoring the liver function closely.
• β-receptor blockers：if there is no hypoxia and airway spasms, selective β1-receptor
blockers are recommended, and observe the pulmonary lesions.Yundai Chen. Chinese Journal of Interventional Cardiology; 2020; 28(2):107-109

54. Use all possible precautions – safety first

55. Some India Specific issues in the media now

61. Thanks
Any questions ?