• ACC/AHA Document Seeks to Improve Understanding of COVID-19’s Cardiovascular Effects

    A new set of standards released Thursday is designed to help develop standardized definitions and establish a framework to allow for a better understanding of how COVID-19 affects cardiovascular health.

    The document, the product of the efforts of a joint task force set up by the American College of Cardiology (ACC) and American Heart Association (AHA) task force, was published online Thursday in the Journal of the American College of Cardiology and Circulation: Cardiovascular Quality and Outcomes.

    The task force performed an extensive literature review for existing data definitions. Their primary sources of information were the Infectious Diseases Society of America Guidelines on the Treatment and Management of Patients with COVID-19 and National Institute of Health (NIH) COVID-19 Treatment Guidelines.

    Some key messages of the ACC/AHA document are summarized below.

    Cardiovascular complications

    The document notes that patients with underlying cardiovascular risk factors or established cardiovascular disease have a greater risk of developing severe COVID-19. In addition, COVID-19 can also have cardiovascular consequences for patients regardless of whether they have cardiovascular disease. The experts point out that up to 20% of hospitalized patients show evidence of myocardial injury in the setting of COVID-19. This can happen through COVID-19 activating inflammatory and thrombotic cascades, causing direct viral injury to myocytes or vascular endothelium, and aggravating underlying atherosclerotic and structural abnormalities.

    Acute cardiovascular complications related to SARS-CoV-2 infection include acute heart failure, acute pericarditis, sustained atrial or ventricular arrhythmias, new-onset atrial fibrillation (AF) or atrial flutter, bradyarrhythmias, and cardiogenic shock.

    Patients can also experience new-onset right ventricular dysfunction stemming from acute pulmonary embolism or strain from acute respiratory distress syndrome and elevated pulmonary artery pressures. The document adds that COVID-19 is associated with a higher risk of stroke, transient ischemic attack, and venous and arterial thromboembolic events.

    A large proportion of patients may continue to experience long-term complications following COVID-19 symptoms  4 weeks or more after the index infection, known as post-acute COVID-19 syndrome. Long-term cardiovascular sequelae stemming from COVID-19 include chest pain, palpitations, arrhythmias, cardiomyopathy and thromboembolism. These and other cardiovascular complications can result from direct and indirect viral-mediated cellular damage; procoagulant state; and the immunologic response affecting the structural integrity of the myocardium, pericardium and conduction system.

    Non-cardiovascular complications

    The document describes a broad range of noncardiovascular complications that can stem from COVID-19. SARS-CoV-2 is primarily a respiratory virus that affects the upper airway. In severe cases, COVID-19 can progress into a lower airway condition (pneumonia), progressive respiratory failure (acute respiratory distress syndrome) and many other complications. Besides cardiovascular and pulmonary systems, COVID-19 can contribute to renal, hepatic, hematologic and neurological complications. Pregnant women are at increased risk of severe COVID-19, according to the U.S. Centers for Disease Control and Prevention, and the disease may be associated with pregnancy loss and other adverse pregnancy outcomes.

    Signs and symptoms

    The document notes that signs and symptoms of infection may be similar in both children and adults but that many children are asymptomatic or have only a few symptoms. The most common symptoms in hospitalized children include fever, nausea, cough and shortness of breath. As many as 45% of children found to have SARS-CoV-2 infection were asymptomatic. The virus has also been associated with multisystem inflammatory system in children (MIS-C) and in young adults (MIS-A).

    Diagnosis and therapy

    The writing committee also listed various diagnostic tests, including coronary angiography, imaging studies such as echocardiography, chest computed tomography (CT), cardiac nuclear imaging and brain CT or magnetic resonance imaging (MRI) to diagnose complications of SARS-CoV-2 infection.

    The document says that evidence is accumulating that supports continuing traditional cardiovascular therapies, including angiotensin-converting enzyme (inhibitors) and angiotensin receptor blockers, as these do not appear to increase the risk of SARS-CoV-2 infection.  Therapies directly used for antiviral activity include remdesivir, and others without direct antiviral activity, such as steroids, can be used in selected patients. Intravenous inotropic and vasopressors can be administered in cases of cardiogenic shock and low cardiac output associated with COVID-19.

    The document also lists several other therapies for different clinical scenarios,

    including mechanical support such as Impella or extracorporeal membrane oxygenation (ECMO), electrophysiological procedures, and coronary/vascular/neurovascular revascularization treatment.

    Purpose

    The task force’s intent was not to make recommendations concerning treatment of COVID-19, which the group stressed should follow prevailing COVID-19 management guidelines. The specific purpose of the clinical data standards was to:

    - establish a consistent, universal and interoperable clinical vocabulary for clinical care and research;

    - facilitate data exchange across various systems through standardized definitions; and

    - help in the development of clinical registries, quality improvement programs, outcome evaluations, implementation of clinical guidelines and clinical research.

    The document is also proposed to set the framework for International Classification of Diseases (ICD)-10 code development of COVID-19 related cardiovascular complications and is intended for use by researchers, registry developers and clinicians, according to an ACC news release. The task force committee envisions that data elements could be helpful for communications with patients, inpatient and outpatient clinical programs, public health organizations, electronic health information initiatives, health policy, health insurance coverage and legislation development. The committee did not differentiate the data elements based on specific encounters, such as inpatient versus outpatient.

    Source:

    Bozkurt B, Das SR, Addison D, et al. 2022 AHA/ACC key data elements and definitions for cardiovascular and noncardiovascular complications of COVID-19: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Data Standards. J Am Coll Cardiol 2022 Jun 23. (Article in press)

    Image Credit: Kateryna_Kon – stock.adobe.com

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