An expert panel from the American College of Cardiology (ACC) Cardiovascular Imaging Leadership Council provides suggestions for using multimodality imaging in evaluating cardiovascular complications in patients with COVID-19.
The statement was published online Wednesday in the Journal of American College of Cardiology.
The evaluation and management of patients with suspected or proven cardiovascular complications of COVID-19, the disease cause by severe acute respiratory syndrome coronavirus-2 (SAR-CoV-2), can be challenging. Routine history, physical examination, laboratory testing, electrocardiography and plain X-ray often is enough for working up these patients. However, given the overlap between COVID-19 and typical cardiovascular diagnoses such as heart failure and acute myocardial infarction, advanced imaging techniques to assist in differential diagnosis and management are frequently needed.
Lawrence Rudski, MD, of Jewish General Hospital, McGill University, Montreal, and colleagues provide guidance in several common scenarios of confirmed or suspected COVID-19-infected patients with possible cardiovascular involvement. For each scenario, the authors consider the role of biomarker testing to guide imaging decision-making, provide differential diagnostic considerations and offer general suggestions regarding application of various advanced imaging techniques. In addition, the authors provide treatment algorithms to help in management strategy
The scenarios they cover include chest discomfort with electrocardiographic changes, acute hemodynamic instability, newly recognized left ventricular dysfunction and imaging during the subacute/chronic phase of COVID-19. In addition, the authors provide the role that each imaging modality can be used to help make the cardiac diagnosis.
Rudski and colleagues provide the following guidance:
- Transthoracic echocardiography typically guides cardiovascular management. This may be in the form of an urgent point-of-care ultrasound (POCUS) or a limited study initially, with more complete studies depending on the patient’s presentation.
- ST-elevation myocardial infarction, clear or suspected, usually requires emergent catheterization with a limited role for noninvasive imaging. Less typical presentations of potential acute coronary syndrome may benefit from POCUS and coronary CT angiography. In patients with MI, normal or non-obstructive coronary arteries, cardiac MRI can help distinguish the etiology of myocardial injury.
- In patients with coronary artery disease (CAD) with suspected low-risk acute coronary syndrome, vasodilator stress MRI or radionuclide myocardial perfusion imaging, especially positron emission tomography (PET) if available, can be considered.
- In patients with new LV systolic dysfunction, underlying CAD should be investigated. For those without evidence of CAD, cardiac MRI or PET can provide important insights into the etiology of myocardial dysfunction.
- In the subacute phase of COVID-19, previously detected abnormalities must be followed for potential recovery or progressive disease.
- In all scenarios, risk to the health care workers is an integral part of deciding the type of imaging to pursue, or whether to pursue it.
The authors conclude that the management of cardiovascular complications in patients with COVID-19 presents substantial diagnostic and therapeutic challenges. Selective use of advanced cardiac imaging offers powerful qualitative and quantitative information that can help with patient management.
Rudski L, Januzzi JL, Rigolin VH, et al. Multimodality Imaging in Evaluation of Cardiovascular complications in Patients with COVID-19. J Am Coll Cardiol 2020 Jul 22.