George W. Vetrovec, MD, MACC: First, what type of cardiac symptoms have you seen, and how frequently have patients demonstrated them? Reports suggest that primary respiratory failure is the predominant finding with associated fever, cough, and other "flu-like" symptoms but note that COVID-19 has a broad spectrum of presentations. Is this true, or do you have a different perspective?

Larry S. Dean, MD, FACC: University of Washington Medicine is a four-hospital system, and presentations have varied a bit across the hospitals. Most of our inpatients have had pulmonary manifestations because we were an early COVID-19 hotspot. From a cardiac perspective, the academic medical center serves as a cardiac referral center for a five-state area, so we have seen an uptick in referral of post myocardial infarction complications.

James M. McCabe, MD, FACC: We have seen a number of patients with shortness of breath who end up having a completed papillary muscle rupture from a left circumflex artery completed infarct, or a ventricular septal defect from an right coronary artery infarct. These are patients in whom COVID-19 was a concern originally but was not present. For COVID-19 patients, I would agree with your description and would also put headache on the list.

Sandeep Nathan, MD, MSc, FACC: We have certainly seen cardiac troponin elevations as well as, to some degree, heart failure diagnosed clinically and asymptomatic left ventricular dysfunction by echocardiography. We have not, however, seen fulminant myocarditis to the severity or frequency reported in Italy and New York City. As noted in reports from Spain¹ and elsewhere in the United States, we have seen a sharp decline in ST-segment elevation myocardial infarction (STEMI) and acute coronary syndrome (ACS) presentations to the emergency department, perhaps to an even greater degree than what was estimated (approximately 40%). In health care personnel at our center who have contracted COVID-19, the predominant symptoms have been fatigue, malaise, and loss of taste/olfactory without many respiratory symptoms or fevers reported. Interestingly, the loss of smell and taste seem to persist long after all other symptoms have improved.

Perwaiz M. Meraj, MD, FACC: There is definitely a broad spectrum of presentations for COVID-19-positive patients, which can confuse the initial medical encounter. Predominantly, fever, cough, and flu-like symptoms are common, but we have also seen anosmia, nausea, genitourinary symptoms, headache, and chest pain. The cardiac-like symptoms are not the same as in typical angina; however, both symptoms and electrocardiograms are STEMI masqueraders at times.

Dr. Vetrovec: Also, there have been very few recognized heart attacks with a variety of myocardial injuries associated with COVID-19. Is this your experience? How have you distinguished STEMIs from COVID-19 myocardial injury?

Dr. McCabe: We do not see many STEMIs at baseline, due to the referral nature of our business, but have seen even fewer folks presenting with ACS over the last few months. Most of the patients we are treating currently are being transferred in from other hospitals with complex, late-stage cardiac issues.

Dr. Nathan: Our type 1 STEMI volume and ACS volume dropped by 50% or more. A recent report from Italy found a 58% increase in out-of-hospital cardiac arrest (OHCA),³ which was strongly correlated with the rise in COVID-19 cases in the region. The numbers in Chicago are difficult to track because emergency medical services have reportedly been discouraged from bringing OHCA to emergency departments without return of spontaneous circulation, as they might have in months past. Thus, many of the OHCA cases may be ending with death in the field. Myonecrosis (type 2 MI) in critically ill COVID-19 patients appears to be common,² and has an even higher incidence than what was reported in Wuhan (22%). We have been somewhat selective about catheterization in these patients, relying on biomarker trends, objective signs/symptoms, or hemodynamic/electrical instability to help inform the decision to proceed with invasive diagnostics and therapeutics.

Dr. Meraj: We have seen a significant (60%) decrease in STEMI from 2019 to 2020 in the same time period, and it is likely due to people being fearful of coming into the hospital. Although we have seen STEMI masqueraders, which are typical of the cytokine storm mediated myocardial injury, different from any presenting STEMI.

Dr. Vetrovec: STEMIs are down for patients without COVID-19, as published.⁴ Do you think out-of-hospital deaths have increased, suggesting that people have avoided coming to hospitals with dire consequences?

Dr. McCabe: Personally, I don't think STEMIs aren't happening. I think STEMI presentations are down but the STEMIs themselves are happening. What we're currently seeing are quite a few late sequalae of completed infarcts including a few patients told by their doctors to shelter in place and not to come to the hospital!

Dr. Nathan: As stated, that has been our experience as well in Chicago, and my strong sense is that we are missing many acute cardiac events. The reluctance on the part of patients to present to medical centers during this time is palpable. Many patients with planned procedures will call even a few hours before and cancel because of the concern of infection risk. I am certain this is playing a role in acute cases as well.

Dr. Meraj: I do believe that is true. At least in part this is the cause of the decrease in STEMI volumes, but there may be other factors as well.

Dr. Vetrovec: Although COVID-19 is a primary respiratory disease, 20%⁵ of patients develop severe cardiac symptoms, with hypotension reported frequently. Have you or your colleagues had experience with intra-aortic balloon pump, extracorporeal membrane oxygenation (ECMO), or percutaneous ventricular assist devices (pVADs) in this setting? Why or why not?

Dr. McCabe: We have not been treating COVID-19 patients with pVADs in part because multiorgan failure and cardiogenic shock are very late-stage findings that don't respond well to any therapy and in part because the systemic inflammatory response syndrome phenomenon underlying this phenotype is not aided by pVADs. We have had some patients on venous venous (VV) ECMO for oxygenation. We've also used plenty of pVADs for patients with cardiac complications of completed infarcts who were short of breath to start but never had COVID-19.

Dr. Nathan: Our multidisciplinary ECMO and shock teams sat down early in the course of the pandemic and charted out criteria for mechanical circulatory support (MCS)/ECMO in these patients. We have selectively used VV ECMO, oxy-right ventricular assist devices, and intra-aortic balloon pumps in these patients. Our criteria mirror many of the criteria put forth by Extracorporeal Life Support Organization a short while later. We apply pretty strict exclusion criteria aimed at utilizing intense resources for those patients with the greatest opportunity to benefit.

Dr. Meraj: We have had some experience with MCS. IABP was ineffective but the only option in selected patients. ECMO guidelines were created by our group, and many patients did not meet the criteria to allow for resource utilization. In the end, VV ECMO was used and was 60% effective, while venoarterial ECMO was used in 1 patient who unfortunately is still on it.

Dr. Vetrovec: You must have a huge backlog of patients whose "elective" procedures have been postponed. Have you seen adverse events in the patients in-waiting? Do you plan to triage patients by order of restarting testing and procedures? If so, how?

Dr. Dean: We have seen a tremendous drop in elective procedures since Washington's Governor's proclamations discouraged them in early March in order to have adequate intensive care unit capacity and to conserve personal protective equipment (PPE). We have been doing urgent cases all along but had a very restrictive definition.

Dr. McCabe: We developed a triage system right from the start so that our highest risk and most vulnerable patients were not really put off. It has helped that the academic medical center was never overrun with COVID-19 patients as was the case in some other institutions, including our community-based hospitals.

Dr. Nathan: In response to reported decompensation of some patients on our "waiting list," we began performing outpatient cases associated with any degree of urgency, and we will open the laboratory further to outpatients with mandatory COVID-19 testing 48-72 hours before for catheterization and electrophysiology laboratory and operating room cases. Fortunately, we have not seen any catastrophic consequences of waiting, but that is likely because we have tasked team members with regularly reaching out to rescheduled patients just to check in.

Dr. Meraj: We have not seen significant levels of adverse events. We have been calling and speaking to them weekly to determine if they can come in earlier based on clinical need.

Dr. Vetrovec: Finally, what are your overall insights? What observations would you like to make? Perhaps a comment on self-protection and personal risk for the medical professionals. What else should we know?

Dr. Dean: As mentioned, University of Washington Medicine has been very proactive in how it handled the pandemic, including early restriction of visitors, segregation of COVID-19 inpatients, stopping all elective surgeries, and now requiring all inpatients be tested. This was done over the very real concern for adequate PPE for caregivers.

Dr. Nathan: My main insight is that the phenotype of the COVID-19 patient apparently varies quite dramatically from one geographic region to the next. Perhaps there will also be variations between the first wave of the disease and subsequent waves. Within the United States, in many ways it seems a bit like New York City versus almost everywhere else. Perhaps it has to do with population density, comorbidities, the size of the inoculum or other factors. Whatever the case may be, the COVID-19 experience in Chicago has certainly taxed medical systems across the region but fortunately, has not overwhelmed or broken them. As an aside, I don't think most providers were prepared for the feelings of uncertainty and the recognized possibility of harm to team members, as one experiences when performing invasive and aerosol-generating procedures on known COVID-19-positive patients. You become acutely aware of the fact that there is yet so much to learn about this novel disease and its potential sequelae.

Dr. Meraj: The most important aspect of COVID is PPE for health care workers and a clinical need for appropriate use of all cardiovascular procedures. Surgery versus percutaneous coronary intervention should not be the focus; rather, the focus should be how to achieve the best patient care outcomes.

References

1. Romaguera R, Cruz-González I, Jurado-Román A, et al. Considerations on the invasive management of ischemic and structural heart disease during the COVID-19 coronavirus outbreak. Consensus statement of the Interventional Cardiology Association and the Ischemic Heart Disease and Acute Cardiac Care Association of the Spanish Society of Cardiology. REC Interv Cardiol 2020;2:112-7.
2. Bangalore S, Sharma A, Slotwiner A, et al. ST-Segment Elevation in Patients With Covid-19 - A Case Series. N Engl J Med 2020;Apr 17:[Epub ahead of print].
3. Tam CCF, Cheung KS, Lam S, et al. Impact of Coronavirus Disease 2019 (COVID-19) Outbreak on ST-Segment-Elevation Myocardial Infarction Care in Hong Kong, China. Circ Cardiovasc Qual Outcomes 2020;13:e006631.
4. Baldi E, Sechi GM, Mare C, et al. Out-of-Hospital Cardiac Arrest During the Covid-19 Outbreak in Italy. N Engl J Med 2020;Apr 29:[Epub ahead of print].
5. Wu Z, McGoogan JM. Characteristics of and Important Lessons From the Coronavirus Disease 2019 (COVID-19) Outbreak in China: Summary of a Report of 72 314 Cases From the Chinese Center for Disease Control and Prevention. JAMA 2020;Feb 24:[Epub ahead of print].

Clinical Topics: Acute Coronary Syndromes, Arrhythmias and Clinical EP, Cardiac Surgery, Cardiovascular Care Team, Congenital Heart Disease and Pediatric Cardiology, COVID-19 Hub, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Stable Ischemic Heart Disease, Vascular Medicine, SCD/Ventricular Arrhythmias, Cardiac Surgery and Arrhythmias, Cardiac Surgery and CHD and Pediatrics, Cardiac Surgery and Heart Failure, Cardiac Surgery and SIHD, Congenital Heart Disease, CHD and Pediatrics and Arrhythmias, CHD and Pediatrics and Imaging, CHD and Pediatrics and Interventions, Acute Heart Failure, Mechanical Circulatory Support, Interventions and ACS, Interventions and Imaging, Interventions and Structural Heart Disease, Interventions and Vascular Medicine, Angiography, Nuclear Imaging, Chronic Angina

Keywords: COVID-19, Coronavirus, Coronavirus Infections, severe acute respiratory syndrome coronavirus 2, Shock, Cardiogenic, Extracorporeal Membrane Oxygenation, Pandemics, ST Elevation Myocardial Infarction, Heart-Assist Devices, Outpatients, Triage, Acute Coronary Syndrome, Incidence, Myocarditis, Out-of-Hospital Cardiac Arrest, Olfaction Disorders, Heart Septal Defects, Ventricular, Coronary Angiography

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