Upload
others
View
3
Download
0
Embed Size (px)
Citation preview
Cardiovascular Complications of COVID-19:
A focus on Post-Acute Sequelae of COVID-19 (PASC)
Amanda K. Verma, MD, FACC
Assistant Professor of Medicine
Department of MedicineCardiovascular Division
Section of Heart Failure and Cardiac Transplantation
DepartmentDivision
Disclosures
• None
DepartmentDivision
Post-Acute Sequelae of COVID-19 (PASC)
• Long COVID, ”long haulers,” post COVID syndrome
• Physical and mental health consequences that are present for 4 or more weeks after SARS-CoV-2 infection1
• Includes general complications of prolonged illness/hospitalization and specific effects of SARS-CoV-2 infection
“Evaluating and Caring for Patients with Post-COVID Conditions: interim Guidance.” Centers for Disease Control. June 2021. https://www.cdc.gov/coronavirus/2019-ncov/hcp/clinical-care/post-covid-index.html
DepartmentDivision
Post-COVID Recovery
• In a study of 143 patients in Italy who were hospitalized for infection
• 73% had interstitial pneumonia during hospitalization, mean hospital LOS 13.5 days
• Assessed at mean of 60 days after onset of initial symptoms
• Only 12.6% were completely free of any symptoms
Carfi et al. Persistent symptoms in patients after COVID-19. JAMA. Aug 2020.
DepartmentDivision
PASC/Post-COVID Syndrome• Most patients have mild course of COVID-19 infection
(85%)1
• Predictors of persistent symptoms2:
1Tenforde et al. Symptom duration and risk factors for delayed return to usual health among outpatients with COVID-9 in multistate health care systems network – United States, March-June 2020. MMWR Morb Mortal Wkly Rep. Jul 2020. 2Carvalho-Schneider et al. Follow-up of adults with noncritical COVID-19 two months after symptom onset. Clin Microbiol Infect. Feb 2021.
DepartmentDivision
Post-COVID and Myocarditis – should we be worried?
• Several papers published looking at patients recovered from COVID-19 and then underwent cardiac MRI that showed abnormalities
• Controversy as to what this means and implications
• Asymptomatic patients need CMR?
DepartmentDivision
DepartmentDivision
Take away points from initial literature
• Variable presentations of patients although studies noted patients were “asymptomatic”
• Small number of patients
• Inconsistent patterns of T1/T2/LGE in unexpected distributions
• No follow-up or prior imaging
DepartmentDivision
• Healthcare workers
• Few comorbidities• 18% tobacco users
• 7% HTN
• 2% DM
• Phenotyping around 6 months post COVID+ testing
• Minimal residual symptoms
• Primary endpoints• LVEF, LVEDDi, LGE%, septal T1,
septal T2
• Secondary endpoints• LV mass, LA area, GLS, septal
ECV, aortic distensibility
• Other endpoints• HR, NT-proBNP, hsTnT, BP
DepartmentDivision
Who and when to image?
DepartmentDivision
DepartmentDivision
DepartmentDivision
Who and when to image?
• My practice:• Ongoing symptoms (especially chest pain) without known cause
• Abnormal TTE (reduced LVEF, abnormal strain, WMA)
• New arrhythmia (excluding sinus tachycardia)
DepartmentDivision
Cardiovascular PASC
• Blood pressure fluctuations – relative hypertension versus orthostatic hypotension
• Palpitations and tachycardia• Atrial arrhythmias
• POTS, inappropriate sinus tachycardia
• Chest pain• Plaque instability/rupture in setting of underlying risk factors
• Musculoskeletal
• Pericarditis-like pain
• Shortness of breath
• Exercise intolerance
DepartmentDivision
Underlying mechanisms of CV-PASC
• Autonomic dysfunction
• Inflammatory response
• Endothelial dysfunction, +/- microvascular dysfunction
• Direct viral jury
DepartmentDivision
Post-COVID Cardiology Clinic• Goal: comprehensive cardiac evaluation of patients with new
onset cardiac symptoms during or following COVID-19 infection
History - Symptoms at time of acute infection- Time course of symptoms- New symptoms- Medications taken at time of acute infection- Review of smart watch HR trends
Physical Exam - Orthostatic vital signs- Ambulatory heart rate
Baseline Screening Tests
- EKG- Inflammatory markers: CRP, ESR, D-Dimer, Ferritin- Cardiac biomarkers: NT-proBNP, high sensitivity
troponin
Additional Testing - TSH, free T4- PA & Lateral CXR- 6 min walk test- PFTs- Holter patch monitor- Transthoracic echocardiogram- Cardiac MRI- Stress testing
DepartmentDivision
Post-COVID Cardiology Clinic ExperienceAnecdotal Treatment Strategies
Palpitations/Tachycardia
- Low dose beta blocker (metoprolol succinate)- Ivabradine- Diltiazem – less effective
Hypertension - Carvedilol (especially if component of tachycardia)
- ACE-i/ARB- CCB (i.e. amlodipine) or MRA – less effective
POTS - Hydration, salt loading, compression stockings- Fludrocortisone
Myocarditis - Beta blocker and ACE-i/ARB - Activity restriction followed by Cardiac Rehab- NSAIDs/colchicine for chest pain
Dyspnea of unclear etiology
- Albuterol inhaler prior to exertion
Chest pain of unclear etiology
- scheduled NSAIDs- Gabapentin- colchicine
DepartmentDivision
Post-COVID Cardiology Clinic Experience
• Aspirin?• Hypercoagulability is established in acute infection
• Unclear benefit in post-COVID syndrome
• Many patients with ongoing symptoms and elevated inflammatory markers
• Oral contraceptive therapy
• Steroids?• No data in post-COVID setting, although appears helpful in MIS
• Anecdotally not helpful
• Vaccination?• No significant improvement in symptoms
• Safe for patients with history of COVID-19
• Follow-up?• How long to take medications
DepartmentDivision
COVID-19 Vaccination
• Informed consent
• BENEFITS >>>>>> Risks
Rosenblum HG et al. Use of COVID-19 Vaccines after Reports of Adverse Events Among Adult Recipients of Janssen (Johnson & Johnson) and mRNA COVID-19 Vaccines (Pfizer-BioNTech and Moderna): Update from the Advisory Committee on Immunization Practices—United States, July 2021. Morbidity and Mortality Weekly Report.
DepartmentDivision
Serious adverse events
• Johnson & Johnson:• Thrombosis with thrombocytopenia syndrome (TTS) - venous or
arterial thrombosis and thrombocytopenia
• Guillain-Barre syndrome (GBS) – autoimmune neurologic disorder characterized by ascending weakness and paralysis
• 3,000-6,000 cases reported annually
• mRNA Vaccines – Pfizer or Moderna:• Myocarditis/cardiac inflammation
DepartmentDivision
Johnson and Johnson – as of 6/30/2021
Doses administered Approx 12.6 million
GBS (between 2/27-6/30/21) • 100 cases reported, 14 confirmed
• Rate: 7.8 per 1 million (0.00078%) – 20.2/million (0.002%)
• Median age: 57• 61% males• Median time to onset 13 days• 1 death
TTS (through 7/8/21) • 38 cases• More common in females aged
30-49• Rate: 8.8 per 1 million
(0.00088%• 4 patients died
DepartmentDivision
mRNA – as of 6/30/2021
Doses administered Approx 141 million
Myocarditis • 497 cases reported• 3.5 cases per million
(0.00035%)• Highest amongst males ages
18-29• No confirmed deaths
DepartmentDivision
Benefits >>>> Risks