Tata Laksana Terapi pada Pasien

Infeksi dengan Komorbid Jantung

Dr. dr. Novita G. Liman, Sp.JP, FIHA
RSUD Pakuhaji Kab. Tangerang
Cardiovascular manifestations
of coronavirus infection

Eur Heart J. 2020. 10.1093/eurheartj/ehaa231

Cardiac Involvement

Circulation. 2020. 10.1161/CIRCULATIONAHA.120.317055

 Myocardial Injury

• Cardiac injury: Cardiac biomarkers (hs-TNI) above the 99th-percentile upper reference limit

• N= 416
• with cardiac injury: 82 (19.7%)
• w/o cardiac injury: 334 (80.3%)

JAMA Cardiology. 2020. 10.1001/jamacardio.2020.0950

 COVID-19 Clinical Course:
N=191, 54 deaths

• Patients with cardiac injury had more baseline co-morbidities

• Older: 74 years vs 60 years
• HTN: 59.8% vs 23.4%
• Diabetes: 24.4% vs 12.0%
• Coronoary heart disease: 29.3% vs 6.0%
• Cerebrovascular disease: 15.9% vs 2.7%
• CHF: 14.6% vs 1.5%
• COPD: 7.3% vs 1.8%
• Cancer: 8.5% vs 0.6%

JAMA Cardiology. 2020. 10.1001/jamacardio.2020.0950

Increased Mortality

JAMA Cardiology. 2020. 10.1001/jamacardio.2020.0950

 Myocardial Injury
ACC statement on use of Troponin and BNP in COVID-19

• Significant proportion of COVID-19 patients with elevated cTnI

• ?Demand ischemia
• ?Plaque rupture
• ?Direct non-coronary myocardial injury
• ?Cytokine storm
• Similary, BNP is elevated in COVID-19, unclear cause
• “..measure troponin or natriuretic peptides if diagnosis of acute MI or HF being considered on
clinical grounds”
ACS and STEMI in COVID
Patients
the guidelines

SCAI guidelines 2020. doi.org/10.1002/ccd.28887

Cardiomyopathy/Myocarditis
 Elevated Troponin Differential

• True Myocarditis
• Stress induced
• Coronary Endothelial Dysfunction
• Hypoxia/Acidosis mediated
• Myocardial depression due to cytokine storm
 Arrhyhtmias

• Arrhythmia incidence 16.7% in one series (n=138)

• VT/VF incidence 5.9% in another series (n=187)

• Malignant tachyarrhyhmias + troponin elevation —> consider myocarditis

Wang D, et al. JAMA 2020;323(11):1061-1069.

Guo T, et al. JAMA Cardiol. Epub 3-27-20.
Driggin E, et al. JACC 2020. doi.org/10.1016/jacc.2020.03.031
EACVI Recommendations

Eur Heart J. 2020. 10.1093/ehjci/jeaa072

 EACVI Recommendations
Key point 1

• Important considerations in patients with suspected or confirmed COVID-19

• Cardiac imaging should be performed if appropriate and only if it is likely to substantially

change patient management or be lifesaving
• Use the imaging modality with the best capability to meet the request, but consider also the
safety of medical staff regarding exposure
• Elective non-urgent and routine follow-up exams may be postponed or even cancelled

Eur Heart J. 2020. 10.1093/ehjci/jeaa072

 EACVI Recommendations
Key point 2

• Risks of contamination in patients with suspected or confirmed COVID-19 include

• Possible/significant risk of infection for professionals (technicians, physicians, nurses, other

personnel)
• Possible/significant risk of contamination of equipment and facilities
• Risk of widespread contamination due to transportation of critically ill or high-risk patients—
the echo machine should be brought to the patient
• Prolonged duration of a cardiac imaging study will increase the likelihood of contamination

Eur Heart J. 2020. 10.1093/ehjci/jeaa072

 EACVI Recommendations

• Echocardiography should not routinely be performed in patients with COVID-19 disease

• A focused cardiac ultrasound study (FoCUS) is recommended to reduce the duration of exposure
• Chest CT is frequently used to confirm COVID-19 pneumonia and might provide possible synergies
and opportunities of cardiac imaging
• Coronary CT angiography can exclude or confirm an acute coronary syndrome in COVID-19
pneumonia where elevated troponins are common
• Positive troponins and myocardial dysfunction or severe arrhythmia suggestive of Tako-tsubo or
myocarditis may be an indication for acute CMR if of vital importance for treatment, and patient can
be safely transferred for imaging

Eur Heart J. 2020. 10.1093/ehjci/jeaa072

 Kesimpulan

• Penggunaan ACEI/ARB sesuai indikasi

• Keterlibatan kardiovaskular—> troponin dan natriuretic peptide
• Panduan ACS dan STEMI—> initial terapi medikamentosa
• Miokarditis dan aritmia
• Pemeriksaan imaging/ekokardiografi dengan mempertimbangkan safety staf/personil