In covid-19 patients

dr. Dyah Samti Mayasari, Ph.D, Sp.JP

 SARS-CoV-19 INFECTION
● SARS-CoV-2 è is an RNA virus that utilizes the angiotensin converting enzyme 2 (ACE2)
receptor to enter cells.
● (ACE2) located in several tissues è the lungs, heart, kidneys, gastrointestinal tract,
vasculature, and skin.
● Over 7.5% of myocardial cells also express the ACE2 receptor è While the presence of
the ACE2 receptor can account for cardiac injury, the etiology of the cardiovascular
effects that may occur in COVID-19 is likely multifactorial.
● The virus can cause a hyperinflammatory state è leading to vascular inflammation,
cardiac injury, plaque instability, hypercoagulability, and myocardial depression.
CARDIOVASCULAR INVOLVEMENT
IN covid19
Those with COVID-19 and pre-existing
cardiovascular disease have an
increased risk of severe disease and
death

Therapies under investigation for

COVID-19 may have cardiovascular
side effects of arrhythmia.

COVID-19 is associated with multiple

direct and indirect cardiovascular
complications

Cardiac Involvement of COVID-19: A Comprehensive Review.

Chang, Wei-Ting et al. The American Journal of the Medical
Sciences, Volume 361, Issue 1, 14 - 22
 Incidence of cardiac injury after
COVID-19 is 19.7%

Patients with cardiac injury:

üRequire noninvasive and
invasive mechanical ventilation
üHigher incidence of
complications such as kidney
injury, electrolyte disturbances
and coagulation disorders
üHigher case fatality rate

Strict monitoring of cardiac function

using bedside echocardiography,
ECG, and standard biomarkers
have prognostic value in COVID-19
patients

Chiara Robba, Denise Battaglini, Paolo Pelosi & Patricia R. M.

Rocco (2020) Multiple organ dysfunction in SARS-CoV-2: MODS-
CoV-2, Expert Review of Respiratory Medicine, 14:9, 865-
868, DOI: 10.1080/17476348.2020.1778470
 potential mechanisms linking covid-19 to acute
myocardial infarction
Pro-inflammatory state Endothelial & vascular injuries
promote destabilization of a coronary atherosclerotic enhances inflammation causing coronary vasospasm,
plaque (contains inflammatory cells that proliferate, secrete thrombosis, and myocardial perfusion defects
cytokines, and stimulate smooth muscle cells to form a
fibrous cap)

Oxygen SUPPLY & DEMAND MISMATCH

reduced oxygen supply vs increased myocardial oxygen
demand due to sympathetic system activation, tachycardia,
hypotension, and hypoxemia

Toscano O, Cosentino N, Campodonico J, Bartorelli AL and Marenzi G (2021) Acute Myocardial

Infarction During the COVID-19 Pandemic: An Update on Clinical Characteristics and Outcomes.
Front. Cardiovasc. Med. 8:648290. doi: 10.3389/fcvm.2021.648290
Toscano O, Cosentino N, Campodonico J, Bartorelli AL and Marenzi G (2021) Acute
Myocardial Infarction During the COVID-19 Pandemic: An Update on Clinical Characteristics
and Outcomes. Front. Cardiovasc. Med. 8:648290. doi: 10.3389/fcvm.2021.648290
 Patients with STEMI had a :
• greater enzymatic infarct size (increased peak troponin
or creatinine kinase levels),
• lower left ventricular ejection fraction,
• higher intracoronary thrombotic burden, and
• therefore, more frequent in-hospital complications

A higher rate of cardiogenic shock, need for inotropic and

mechanical hemodynamic support, and an increased
incidence of life-threatening ventricular arrhythmias after
successful revascularization of the culprit artery à found in
patients with AMI admitted during the COVID-19 pandemic

Toscano O, Cosentino N, Campodonico J, Bartorelli AL and Marenzi G (2021) Acute

Myocardial Infarction During the COVID-19 Pandemic: An Update on Clinical Characteristics
and Outcomes. Front. Cardiovasc. Med. 8:648290. doi: 10.3389/fcvm.2021.648290
 • The in-hospital mortality for STEMI
increased from 4% to 14% in the same
period of 2019
• The major complications (cardiogenic
shock, life-threatening arrythmias,
cardiac rupture, and severe mitral
regurgitation) were also increased
from 10% to 19%
• A raised length of stay in hospitals
was observed to be increased during
the peak of the pandemic (1 March to
30 April 2020)

Toscano O, Cosentino N, Campodonico J, Bartorelli AL and Marenzi G (2021) Acute

Myocardial Infarction During the COVID-19 Pandemic: An Update on Clinical Characteristics
and Outcomes. Front. Cardiovasc. Med. 8:648290. doi: 10.3389/fcvm.2021.648290
A prospective, multicenter, observational cohort study in 7
tertiary Spanish hospitals:
• 187 patients diagnosed with AMI (included in the study)
• 76 NSTEMI patients vs111 STEMI patients
• 17% of all patients were tested COVID-19 positive (37%
NSTEMI and 63% STEMI)
 result
1. Non-COVID-19 patients predominantly had chest pain, whereas COVID-19
patients mainly had respiratory symptoms (e.g. fever and cough)
2. Killip III/IV and GRACE scores were significantly higher in COVID-19 patients
3. No significant differences in left ventricular ejection fraction between the 2
groups
4. COVID-19 patients had higher levels of C-reactive protein at admission and of
peaks levels during hospitalization
5. No significant differences in cardiac troponin at admission and in the peak during
hospitalization
6. The hospital LOS was significantly shorter in non-COVID-19 patients
Jorge Solano-López, José Luis Zamorano, Ana Pardo Sanz, et al. Risk factors for in
hospital mortality in patients with acute myocardial infarction during the COVID-19
outbreak. Rev Esp Cardiol. 2020;73:985-93. DOI 10.1016/j.rec.2020.07.009
 Total mortality and
cardiovascular death were
significantly higher in the
COVID-19 group

The causes of death in

COVID-19 patients were
• ARDS,
• cardiogenic shock after
distal thrombus
embolization from a left
main coronary lesion, and
• cardiac rupture as a
mechanical complication
of STEMI

COVID-19 is an independent
factor related to in-hospital
mortality in patients with AMI
Jorge Solano-López, José Luis Zamorano, Ana Pardo Sanz, et al. Risk factors for in
hospital mortality in patients with acute myocardial infarction during the COVID-19
outbreak. Rev Esp Cardiol. 2020;73:985-93. DOI 10.1016/j.rec.2020.07.009
 Factors causing increased mortality in covid-19
patients
• AMI patients with COVID-19 had more frequent atypical symptoms à
suggestive a respiratory infection (cough and fever) à delayed diagnosis and
treatment à worse outcomes
• Atypical presentation in female and is associated with worse prognosis
• The levels of acute-phase reactant CRP were higher in COVID-19 patients à
reflect systemic and vascular inflammation à can predict future cardiovascular
events
• COVID-19 predisposes patients to thrombotic disease, both in venous and
arterial circulations (due to excessive inflammation, platelet activation, endothelial
dysfunction, and stasis)
Jorge Solano-López, José Luis Zamorano, Ana Pardo Sanz, et al. Risk factors for in
hospital mortality in patients with acute myocardial infarction during the COVID-19
outbreak. Rev Esp Cardiol. 2020;73:985-93. DOI 10.1016/j.rec.2020.07.009
How to diagnose?
 ü Symptom
ü ECG
ü Age
ü Sex
ü Patient’s history
ü Risk factors of CVD

Cameli M, Pastore MC, Mandoli GE, D’Ascenzi F,

Focardi M, Biagioni G, Cameli P, Patti G, Franchi F,
Mondillo S and Valente S (2021) COVID-19 and Acute
Coronary Syndromes: Current Data and Future
Implications. Front. Cardiovasc. Med. 7:593496. doi:
10.3389/fcvm.2020.593496
Troponin elevation –
not merely
myocardial
infarction
Different
etiologies
and
mechanism

Cameli M, Pastore MC, Mandoli GE, D’Ascenzi F, Focardi M, Biagioni G, Cameli P, Patti G,
Franchi F, Mondillo S and Valente S (2021) COVID-19 and Acute Coronary Syndromes: Current
Data and Future Implications. Front. Cardiovasc. Med. 7:593496. doi:
10.3389/fcvm.2020.593496
management
Time is muscle
 management
ACC and American College of Emergency Physicians (ACEP) suggest that for STEMI
patients with positive COVID-19 à transfer to a PCI center should be discussed.
Preferrable to perform fibrinolysis within 30 min of STEMI diagnosis and eventually transfer
to capable center if rescue PCI is needed (performed by experienced operators equipped with
high-level PPE)

Primary pci fibrinolysis

remains the standard of care for STEMI patients for patients in whom PPCI is not feasible,
referred to PCI-capable centers or transferred rapidly initial fibrinolysis is recommended, followed
from non-PCI centers within 120 mins by consideration of transfer to a PCI center
Workflow for the management of STEMI patients in
the context of a COVID-19 outbreak

Eur Heart J, Volume 41, Issue 19, 14 May

2020, Pages 1788–1790,
https://doi.org/10.1093/eurheartj/ehaa266
The Task Force for the management of COVID-19
of the European Society of Cardiology, ESC
guidance for the diagnosis and management of
cardiovascular disease during the COVID-19
pandemic: part 2—care pathways, treatment, and
follow-up, European Heart Journal, Volume 43,
Issue 11, 14 March 2022, Pages 1059–
1103, https://doi.org/10.1093/eurheartj/ehab697
Risk stratification of nstemi
Based on individual risk
• Very high risk à should follow a similar
management of STEMI;

• High risk à follow medical treatment while

waiting for SARS-CoV-2 test results & planning
an early invasive therapy (<24 hours) à if
COVID-19 (+), the patients should undergo ICA
in a COVID-19 hospital

• Low risk à evaluated non-invasively, using

coronary CT (if possible, to exclude other
etiologies) à if low risk is confirmed, follow
conservative strategy

Cameli M, Pastore MC, Mandoli GE, D’Ascenzi F, Focardi M, Biagioni G,

Cameli P, Patti G, Franchi F, Mondillo S and Valente S (2021) COVID-19
and Acute Coronary Syndromes: Current Data and Future Implications.
The Task Force for the management of COVID-19 of
the European Society of Cardiology, ESC guidance
for the diagnosis and management of
cardiovascular disease during the COVID-19
pandemic: part 2—care pathways, treatment, and
follow-up, European Heart Journal, Volume 43,
Issue 11, 14 March 2022, Pages 1059–
1103, https://doi.org/10.1093/eurheartj/ehab697
Cameli M, Pastore MC, Mandoli GE, D’Ascenzi F, Focardi M, Biagioni G, Cameli P, Patti G, Franchi F, Mondillo S and Valente S (2021) COVID-
19 and Acute Coronary Syndromes: Current Data and Future Implications. Front. Cardiovasc. Med. 7:593496. doi: 10.3389/fcvm.2020.593496
CASE STUDY
Nama : Tn. DA aNAMNESIS
Usia : 32 tahun
• Keluhan utama à sesak nafas disertai nyeri dada
• Anamnesis
Pasien mengeluhkan nyeri dada yang
memberat sejak 10 jam yang lalu, karakteristik
seperti ditindih, tidak menjalar. Mual, muntah,
keringat dingin disangkal. Sesak nafas +

Faktor resiko à obesitas (BMI 30,8)

RPD à HT (-), dislipidemia dan DM tidak
diketahui, smoker (+)

Hasil swab antigen COVID-19 (+)

PEMERIKSAAN FISIK
KU : Gelisah
Kesadaran : CM
TD : 100/70 mmHg
S : 36,7 ⁰C
N : 94 x/menit
RR : 24 x/menit
SpO2 : 99% dengan face mask 6 lpm
VAS :6

Pemeriksaan fisik thoraks S1-2 normal,

cardiomegaly (+), bising (-)
Ronkhi (-)
Pemeriksaan ekg
What Should be done?
1. Diagnosis: STEMI anterior extensive Killip I onset 10 jam,
confirmed COVID-19
2. No severe pneumonia and no contraindication of fibrinolysis
 REFERENCES
● Caldeira, D. and Pinto, F., 2021. COVID-19 and myocardial infarction. The Lancet,
398(10315), pp.1963-1964.

● Cameli, M., Pastore, M., Mandoli, G., D'Ascenzi, F., Focardi, M., Biagioni, G., Cameli, P.,
Patti, G., Franchi, F., Mondillo, S. and Valente, S., 2021. COVID-19 and Acute Coronary
Syndromes: Current Data and Future Implications. Frontiers in Cardiovascular Medicine, 7.

● Chang, W., Toh, H., Liao, C. and Yu, W., 2021. Cardiac Involvement of COVID-19: A
Comprehensive Review. The American Journal of the Medical Sciences, 361(1), pp.14-
22.AUTHOR (YEAR). Title of the publication. Publisher

● Fanaroff AC, Garcia S, Giri J. Myocardial Infarction During the COVID-19

Pandemic. JAMA. 2021;326(19):1916–1918. doi:10.1001/jama.2021.19608

● Kornowski R, Orvin K, et al. The Clinical Challenge of ST-Segment Elevation Myocardial

Infarction and COVID-19∗ . J Am Coll Cardiol. 2021 Apr, 77 (16) 2004–2006.

● Lin Zhang, Yongzhen Fan, Zhibing Lu, Experiences and lesson strategies for cardiology from
the COVID-19 outbreak in Wuhan, China, by ‘on the scene’ cardiologists, European Heart
Journal, Volume 41, Issue 19, 14 May 2020, Pages 1788–1790

● Manolis AS, Manolis AA, Manolis TA, Melita H. COVID-19 and Acute Myocardial Injury and
Infarction: Related Mechanisms and Emerging Challenges. Journal of Cardiovascular
Pharmacology and Therapeutics. September 2021:399-414.

● The Task Force for the management of COVID-19 of the European Society of Cardiology,
ESC guidance for the diagnosis and management of cardiovascular disease during the
COVID-19 pandemic: part 2—care pathways, treatment, and follow-up, European Heart
Journal, Volume 43, Issue 11, 14 March 2022, Pages 1059–1103
THANK
you