• Users Online: 536
  • Home
  • Print this page
  • Email this page
Home About us Editorial board Ahead of print Current issue Search Archives Submit article Instructions Subscribe Contacts Login 


 
 Table of Contents  
REVIEW ARTICLE
Year : 2020  |  Volume : 6  |  Issue : 2  |  Page : 132-139

How to run the cardiology service in COVID times? A practical guide


Department of Cardiology, All India Institute of Medical Sciences, New Delhi, India

Date of Submission09-May-2020
Date of Decision17-Jun-2020
Date of Acceptance25-Jul-2020
Date of Web Publication27-Aug-2020

Correspondence Address:
Dr. Sivasubramanian Ramakrishnan
Department of Cardiology, All India Institute of Medical Sciences, New Delhi - 110 029
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jpcs.jpcs_48_20

Rights and Permissions
  Abstract 


Coronavirus disease 2019 (COVID-19) has placed an enormous strain on the health-care systems. In this systematic review, we briefly review the cardiovascular manifestation of COVID and how a cardiology service can be geared to tackle the COVID pandemic. These guidelines are based on how our hospital is being run based on guidelines which have come out from time to time from the Indian Council of Medical Research, WHO, Centers for Disease Control and Prevention, and other health authorities. COVID-19 is more severe in patients with cardiovascular disease and hypertension and may be associated with myocarditis like illness and shock. Patients with preexisting comorbidities have to be handled with extra care, and the manifestation of COVID-19 has to be distinguished from cardiovascular problems. Running a cardiology service requires ensuring preventing cross infection between patients, preventing patients from infecting health-care personal, and this requires precautions at all levels including the outpatient, ward, echocardiography, angiography, and during surgery. All these aspects are discussed. Different wards and different procedures carry a different level of risk requiring different levels of protection which are outlined. There have to be triage areas to screen patients while the COVID reports are coming in, keeping in mind that the patients can be COVID positive even if the reports are negative. Each hospital has to have guidelines in place to handle different cardiac emergencies.

Keywords: AIIMS, cardiology practice, coronavirus, COVID


How to cite this article:
Kapil A, Ramakrishnan S. How to run the cardiology service in COVID times? A practical guide. J Pract Cardiovasc Sci 2020;6:132-9

How to cite this URL:
Kapil A, Ramakrishnan S. How to run the cardiology service in COVID times? A practical guide. J Pract Cardiovasc Sci [serial online] 2020 [cited 2020 Sep 20];6:132-9. Available from: http://www.j-pcs.org/text.asp?2020/6/2/132/293589




  Introduction Top


We are in the midst of a pandemic. The severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) that results in coronavirus disease 2019 (COVID-19) has been declared a pandemic on March 11, 2020, and is affecting the provision of health-care services in countries affected by it world over.[1] As of May 30, 2020, more than 5.95 million cases of COVID-19 have been reported in more than 188 countries and territories, resulting in more than 365,000 deaths.[2] In India, as of May 30, 2020, 173,763 cases of COVID-19 have been reported with 4971 deaths.[3] Health-care workers are at a high risk of contracting this virus as most services require close interaction with the patients. The virus carries a relatively high mortality and morbidity risk, particularly for certain populations like patients with multiple comorbidities.[4]

COVID-19 has placed an enormous strain on the health-care systems of nations where it has spread widely. Implications of COVID-19 for a cardiologist include how to modify standard practice for elective cardiac patients, those who are suspected COVID-19 patients, and those patients with COVID-19 who have either unrelated cardiac conditions or cardiac manifestations of the disease. It merits emphasis that this is a dynamic situation and one for which there are limited data and there are enormous variations in local conditions.

In this systematic review, we briefly review the cardiovascular manifestation of COVID and how a cardiology service can be geared to tackle the COVID pandemic. These guidelines are based on how our hospital is being run based on guidelines which have come out from time to time from the Indian Council of Medical Research (ICMR), WHO, Centers for Disease Control and Prevention (CDC), and other health authorities. Available publications were also sourced.


  Methodology Top


A literature search was done in PubMed/Medline and Google Scholar/Google using the keywords: Corona, COVID-19, Cardiac, Cardiology, Hospital, India, ICMR, CDC, WHO, angiography, surgery, STEMI, acute myocardial infarction, emergency medical system, fibrinolysis, percutaneous coronary intervention, echocardiography, infection control, pneumonia, and safety. Articles which provided new information were reviewed and used for this review and also for developing guidelines for running our cardiology services.

Part one: Cardiovascular manifestations of COVID-19

COVID-19 infections are associated with significant cardiovascular manifestations. Autopsies have shown infiltration of the myocardium with mononuclear inflammatory cells.[5] Similar to Middle East respiratory syndrome and SARS viruses, common cardiac complications associated with COVID-19 are myocarditis, arrhythmias, sudden cardiac death, left ventricular dysfunction, and troponin elevation.[6],[7] The myocardial injury and increased troponin values are likely due to infection-associated myocarditis and ischemia.[8] Some studies have shown that elevated biomarker levels are associated with a significant increase in mortality.[9] Apart from acute complications, COVID-19 is also associated with an increase in hypercoagulability and systemic inflammation, which can persist for a long period after infection.[6],[10]

Hypertension

The prevalence of preexisting hypertension seems to be higher in COVID-19 patients who develop severe disease versus those who do not.[4],[11] The mechanisms underlying this relationship are most likely due to age and associated comorbidities as the confounding factors.[12] Previous speculation suggested that treatment with renin–angiotensin system (RAS) inhibitors may influence the binding of the virus to the angiotensin-converting enzyme 2 (ACE2) receptor, promoting the disease.[13] This is based on some experimental findings, but it is important to state that there is no clear evidence that using RAS inhibitors leads to upregulation of ACE2 receptor in humans.[13],[14] One observational study from Asia, Europe, and North America did not show any harmful association of RAS inhibitors with mortality,[15] and a Chinese study showed that RAS inhibitors were associated with a lower risk of COVID-19 infection and risk of death or complications.[12],[16],[17],[18],[19],[20],[21] Guidelines from multiple cardiovascular societies have stated that patients on RAS inhibitors should not stop their treatment.[22],[23]

Myocarditis

Myocarditis appears in COVID-19 patients several days after initiation of fever which indicates myocardial damage caused by viral infection. The mechanisms may be related to the upregulation of ACE2 in heart and coronaries.[22],[24] Respiratory failure and hypoxia may also cause damage to the myocardium, and immune mechanisms of inflammation may contribute.[8],[22],[24] In severe COVID-19, increases of numerous cytokines including interleukin (IL)-6, IL-2, IL-7, granulocyte colony-stimulating factor, C-X-C motif chemokine 10, chemokine (C-C motif) ligand 2, and tumor necrosis factor-α have all been observed,[25] which correspond to the characteristics of a cytokine release syndrome (CRS). Altered vascular permeability can result in noncardiogenic pulmonary edema and promotes respiratory failure as well as multi-organ dysfunction. High serum IL-6 levels are commonly seen in CRS, which have been associated with mortality.[26]

Chest pain

The symptom of chest pain or tightness is common in patients with COVID-19. It is poorly localized and may be due to underlying pneumonia. Associated profound hypoxemia and tachycardia may result in chest pain and electrocardiographic changes suggestive of myocardial ischemia. Where biomarkers are altered, Type 2 myocardial infarction (MI) may be suggested. Patients with acute coronary syndrome, however, experience the more typical symptoms of ischemia.

Cardiogenic shock

In critically ill COVID-19 patients at risk for cardiogenic shock (CS) (such as those with large anterior MI and acute decompensated heart failure) and sepsis, a mixed etiology of CS and septic shock should be considered in addition to the sole cardiogenic component. Parameters allowing for a differential diagnosis between CS and septic shock, such as the presence of vasodilatation and central venous oxygen saturation values, may be assessed. Important diagnostic testing in patients with suspected CS, including electrocardiogram (ECG), bedside echocardiography, and urgent/emergent coronary angiography should be performed with personal protective equipment (PPE) to ensure best care.

Arrhythmias

There is very limited literature available on the occurrence of arrhythmia in COVID-19. In a study of 138 hospitalized patients with COVID-19 in Wuhan, arrhythmia was reported in 16.7% of total patients and in 16 of 36 patients admitted to the intensive care unit (ICU) (44%).[27] In a subsequent publication by the same institute, ventricular tachycardia (VT) and fibrillation was reported as a complication of COVID-19 in 11 of 187 patients with a significantly higher incidence in patients with elevated troponin values.[9] Hypoxia and systemic inflammation may cause new-onset atrial fibrillation, and consideration should be given to rhythm control and anticoagulation.

Pulmonary embolism

Definite evidence is still lacking, but numerous case reports suggest that the incidence of pulmonary embolism (PE) in COVID-19 infection may be high.[28],[29],[30] Along with COVID-19-associated systemic inflammation, coagulation activation, hypoxia, and immobilization, anticoagulation at standard prophylactic doses should be considered for all patients admitted to the hospital with COVID-19 infection.[31] Patients with COVID-19 present with respiratory distress, chest pain, and hemoptysis, and these symptoms overlap with presentation of acute PE, which may lead to underdiagnosis.[32],[33] It is recommended to only order tests when PE is clinically suspected, but the threshold for suspicion must be kept low. Treatment for PE remains guided by risk stratification, as per previous guidelines for PE.[34] Some investigational drugs may have interactions with novel oral anticoagulants (NOACs), and in such cases, NOACs may be avoided.

Part two: Strategies to run the cardiology department

Outpatient department

A surgical mask should be provided to every patient and health-care provider. Checking of temperature and saturation (optional) and administering a simple screening form for symptoms of COVID is desirable before the patient entry to outpatient department areas. A triage should be performed to assess patient status[35] to risk stratify into suspected cases and not suspected or negative cases. The suspected cases should be sent to a dedicated COVID screening facility for testing and further management, and the other group may be managed with level I protection for health-care workers [Table 1]. [Table 2] outlines the PPE recommendations in the outpatient department.
Table 1: COVID-related personal protection for health-care workers[31]

Click here to view
Table 2: Personal protective equipment recommendations in outpatient department setting[36]

Click here to view


Telemedicine and home drug delivery

The use of telemedicine should be encouraged to minimize the risk of SARS-CoV-2 transmission in both patients and health-care workers. Whenever possible, this technology should be utilized to provide medical advice and follow-up of stable patients and to reserve direct contact for emergency situations. It is advisable that health-care workers make telephonic contact with patients with chronic conditions, such as heart failure, valvular heart disease (VHD), and stable angina, to verify the need for the hospital visit but also to provide psychological support. If feasible, home delivery and mailing of drugs to the patients is a viable option as many patients are visiting the hospital for refilling of medications.

Inpatient cardiac care

Given the nature of cardiovascular diseases, patients will be presenting to the erectile dysfunction (ED) with conditions requiring admission. Newly admitted patients in a cardiology ward should be regarded as possibly infected.[37] All patients and their caregivers should be provided with a surgical mask.[38],[39],[40] If there are adequate resources, there is a benefit in testing all patients, even without COVID symptoms, particularly in areas where there is community transmission. All admitted patients should be managed in the meantime with adequate personal protection while awaiting reverse transcription–polymerase chain reaction results. These patients need to be managed in a dedicated area of the ward. The use of dedicated medical equipment (e.g., blood pressure cuffs, stethoscopes, and thermometers) for confirmed/probable/suspected cases is strongly recommended.[38] If not possible, equipment must undergo disinfection according to local policies. Not suspected or negative cases should be managed in a different area of the ward or a different ward where only COVID-19-negative cases are admitted.[35] PPE recommendations in the inpatient setting is mentioned in [Table 3].
Table 3: Personal protective equipment recommendation in inpatient setting[36]

Click here to view


Emergency department

COVID-19 triage should be performed, and dedicated areas should be identified to separate not suspected from suspected/probable cases. Before performing cardiology consultations, it is advised to carry out a quick telephonic interview to ascertain if the patient has suspected COVID-19 symptoms or risk factors for COVID-19 or suspicious chest X-ray/computed tomography (CT) scan.[35] If any suspicion is present and cardiology advice is urgent, the patient should be considered positive for SARS-CoV-2 infection, and maximum protection measures must be taken level II or level III in case of aerosol-generating procedures.[31] Other ED cases should be managed with level I protection.

Catheterization laboratory

Elective procedures

It is prudent to avoid elective procedures in an effort to preserve resources and avoid exposure of patients to the hospital environment where COVID-19 may be more prevalent. It also preserves hospital bed capacity, which may be facing a shortage depending on the prevalence of COVID-19 in the area. The classification of a procedure as elective requires clinical judgment, and procedures such as percutaneous coronary intervention (PCI) for stable angina, patent foramen ovale closure, or peripheral vascular intervention for claudication may be deferred.

ST-Segment elevation myocardial infarction patients

The Chinese protocol relied on a rapid testing method and reliance on fibrinolytic therapy.[41] This can be problematic in areas where the rapid test is not available and in institutions where primary PCI is routine for ST-segment elevation MI (STEMI) patients. There is no time to wait for nasopharyngeal swab result, so the procedure should be performed in a dedicated COVID-19 catheterization laboratory (where only COVID-19-positive cases are done), and all STEMI patients should be considered as COVID-19 positive. As per the European Society of Cardiology guidelines, primary PCI remains the reperfusion therapy of choice if feasible within the usual time frame and performed in hospitals approved for the treatment of COVID-19 patients in a safe manner for both health-care providers and other patients.[31] Immediate complete revascularization should be considered if clinically indicated to avoid repeat procedures and reduce hospital stay. Left ventriculography should be done during the procedure to avoid echocardiography.[31] As per the American College of Cardiology/Society for Cardiovascular Angiography and Interventions recommendations, in the patient with known COVID-19 and STEMI, the balance of staff exposure and patient benefit will need to be weighed carefully, and fibrinolysis can be considered an option for the relatively stable STEMI patient with active COVID-19.[42] In patients with active COVID-19 in whom primary PCI is to be performed, appropriate PPE should be worn, especially given the limited ability to take a history from the patient as well as the potential for clinical deterioration in STEMI cases. The use of Powered Air-Purifying Respirator systems may also be considered, especially for patients who may be vomiting or those who may require cardiopulmonary resuscitation (CPR) and/or intubation. The vast number of catheterization laboratories has either normal or positive ventilation systems and is not designed for infection isolation. Therefore, laboratories will have to be sterilized and cleaned after every procedure.

Non-ST-segment elevation myocardial infarction patients

For most patients with non-STEMI (NSTEMI) and suspected COVID-19, time should allow for diagnostic testing for COVID-19 before cardiac catheterization. In appropriately selected cases of patients with known COVID-19 and NSTEMI, conservative therapy may be sufficient based on the patient's risk.[42] Noninvasive imaging using CT may help risk stratify patients and avoid an invasive approach allowing early discharge.[43] Unstable NSTEMI patients whose instability is due to the acute coronary syndrome (rather than other factors) may be considered under the STEMI protocol.

Patients requiring intubation and/or cardiopulmonary resuscitation

Intubation, suction, and active CPR result in aerosolization of respiratory secretions increasing likelihood of exposure to health-care workers. Patients who are already intubated pose less of a transmission risk as the ventilation is through a closed circuit. Patients with COVID-19 or suspected COVID-19 requiring intubation should be intubated before arrival to the catheterization laboratory.[42] Further, the threshold to consider intubation in a patient with borderline respiratory status may need to be lowered in order to avoid emergent intubation in the catheterization laboratory.

Other laboratory procedures

Staff shortages should be anticipated based on both the possibility of infected/exposed/quarantined staff. Given the infectious risk of transporting patients from wards to the catheterization laboratory, some procedures routinely done in the catheterization laboratory should be considered for bedside performance, for example, pericardiocentesis, insertion of intra-aortic balloon pump, or temporary pacemaker. For known COVID-19-positive patients, restriction of cases to a dedicated laboratory may be considered.

Electrophysiology laboratory

Most of the electrophysiology (EP) laboratory activities are being markedly reduced or suspended in areas that have been severely affected by COVID-19 outbreak. All patients with clinical indication for an EP procedure should undergo a nasopharyngeal swab immediately after admission. In critical conditions such as syncope and complete heart block, patients should immediately be transferred to the EP laboratory and undergo pacemaker implantation under level II protection measures [Table 1]. After the procedure, these patients should be transferred to a dedicated ward area where COVID screening may be performed. In COVID-positive patients, ablation procedures should be deferred, and anti-arrhythmic drugs should be used.[31] If procedure is necessary, the number of operators should be limited to the essential. Implantable devices that have remote control technology are desired. Cleaning and sanitation of laboratory should be performed after every procedure.

Echocardiography

Given the risk of cardiovascular complications in the setting of COVID-19, including preexisting cardiac disease, acute cardiac injury, and drug-related myocardial damage, echocardiographic services will likely be required in the care of patients with suspected or confirmed COVID-19. Consequently, echo providers will be exposed to SARS-CoV-2.

When to use?

The appropriate use criteria (AUC) should be utilized to guide echocardiographic imaging. If the examination is unlikely to yield clinically important information in the short term, even if indicated as per the AUC, it may be deferred. In cases where echocardiography is deemed required, knowing the status of a patient allows for the appropriate application of PPE and its conservation when not needed, in addition to reducing the exposure risk to echocardiography personnel. Transesophageal echoes (TEEs) carry a heightened risk of spread since they may provoke aerosolization of a large amount of virus due to coughing or gagging that may result during the examination. The use of contrast-enhanced CT and magnetic resonance imaging (MRI) has emerged as an alternative to TEE for exclusion of left atrial appendage thrombus before cardioversion.[44] The use of these tests to avoid an aerosolizing procedure should be balanced against the risk of transporting a patient through the hospital to the CT or MRI scanner, the need to disinfect the CT or MRI room, and iodinated contrast and radiation for CT and long scan times for MRI.

Where to perform?

The portability of echocardiography affords a clear advantage in imaging patients without having to move them and risk virus transmission in the clinic or hospital. All forms of echocardiography (including chemical stress tests) can be performed in emergency departments, hospital wards, ICUs, operating theaters, recovery areas, and structural heart and EP procedure laboratories, in addition to echocardiography laboratories. Bedside performance is encouraged if an adequate study can be performed.

Equipment

Equipment care is critical in the prevention of transmission. Measures such as covering probes and machine consoles with disposable plastic and foregoing the use of electrocardiography (ECG) stickers may be done. It must be balanced against the potential of suboptimal images and prolongation of scan time. Certain machines or probes may be set aside for use on patients with suspected or confirmed infection. Echocardiogram machines and probes should be thoroughly cleaned, ideally in the patient's room and again in the hallway. The risk of transmission also occurs in scan reading rooms. Keyboards, monitors, mice, chairs, phones, desktops, and doorknobs should be frequently cleaned, and ventilation provided wherever possible.[45]

Part three: Management of specific conditions

Valvular heart disease

VHD has not been specifically linked to increased morbidity or mortality in COVID-19. The symptoms of disease progression may mimic those of lung infection. VHD may aggravate the course of COVID-19 and complicate hemodynamic management of cytokine storm, ARDS, or sepsis. Elective surgical or transcatheter interventions require significant resources and should be inappropriate during the pandemic. However, patients with severe disease may require close monitoring and be asked to report in case of progress of symptoms. In a scenario where a patient requires early intervention, the use of less invasive procedures (such as transcatheter aortic valve implantation) may help in reducing ICU stay and hospital admission.[31] Clinical decision-making using the Heart Team approach remains critical for best care.

Chronic heart failure

The risk of COVID-19 in this group may be higher because of advanced age and multiple comorbidities. Routine clinical assessment including temperature measurement, ECG (arrhythmias, MI, and myocarditis), chest X-ray (pneumonia and cardiomegaly), and laboratory measurements (erythrocyte sedimentation rate, C-reactive protein, and lymphocytopenia) can provide a diagnostic clue. Echocardiography and chest CT may add additional diagnostic information. Patients with chronic heart failure should strictly follow protective measures to prevent infection. Stable heart failure patients should refrain from visiting the hospital. Optimal medical therapy should be continued. Telemedicine should be considered whenever feasible to follow up stable patients. As mentioned in the section on hypertension, RAS inhibitors should be continued in these patients as well, irrespective of COVID-19 status. COVID-19 patients may have hypotension due to dehydration and hemodynamic deterioration, and adjustment of medication doses should be considered in such a scenario.

Arrhythmogenic and QTc prolongation of coronavirus disease 2019 therapies

Treatment strategies for COVID-19 use a combination of several drugs which are being used “off-label.” Drugs include chloroquine/hydroxychloroquine, lopinavir–ritonavir, remdesivir, and azithromycin.[46],[47],[48],[49] Glucocorticoids, interferons, and tocilizumab are also being used.[50]

Hydroxychloroquine is being used as a drug for prophylaxis as well as treatment against COVID-19 in India. One major concern with these drugs is the very rare risk of QTc prolongation and torsades de pointes (TdP)/sudden death. A recent meta-analysis on arrhythmogenic potential of quinolones and structurally similar antimalarials suggested that this risk is minimal.[51] However, during COVID-19 infection, the QT-related risk may be increased by concomitant use of other QTc-prolonging drugs and electrolyte imbalances (hypokalemia, hypomagnesemia, and/or hypocalcemia). A second concern with hydroxychloroquine is the potential for conduction disturbances, although these are rare and appear to be linked mostly to long-term treatment.

Azithromycin is another common drug being used in India for COVID-19 treatment. It has been associated with QTc prolongation and TdP, mainly in individuals with additional risk factors.[52],[53] Two studies from Africa have looked at safety profile of using this combination for the treatment of malaria and showed acceptable safety profile.[54],[55]

QTc prolongation with such drugs may rarely lead to polymorphic VT/TdP. [Figure 1] provides a practical flowchart for the management of patients to prevent TdP and for timing and repetition of ECG and QTc measurements. All modifiable (hypocalcemia, hypokalemia, hypomagnesemia, concomitant use of QTc-prolonging medications, and bradycardia) and nonmodifiable (congenital long QT syndrome, known QT prolongation on QT-prolonging drugs, females, age more than 65, structural heart disease, hypertrophic cardiomyopathy, decompensated heart failure, and renal or liver impairment) risk factors for QTc prolongation should be checked in every patient. Serum potassium should be kept at higher end >4.5 mEq/L.[56] Baseline ECG should be performed, and baseline QTc >500 ms is at higher risk for TdP. In patients with recent ECG showing normal QTc and no evidence of cardiovascular alteration due to COVID-19, it may be appropriate to not do baseline ECG, as every ECG exposes health-care workers and equipment. ECG should be performed once on treatment. If the patient has a QTc ≥500 ms or shows a △ QTc ≥60 ms, consideration should be given to either switching to a drug with a lower risk of QTc prolongation or reducing the dose administered. Close surveillance of the QTc (preferably including telemetry for arrhythmia monitoring) and electrolyte balance are mandatory.
Figure 1: Practical flowchart for the management of patients to prevent torsades de pointes, for guidance on the timing and repetition of ECG recording, and on QTc measurements that may alter therapy.[31]

Click here to view



  Conclusion Top


Running the cardiology service during a pandemic presents to us unique challenges. Controlling the pandemic while providing optimal care to the cardiology patients has a fine balance which has to be maintained as much as possible. The COVID-19 pandemic also brings with it new cardiovascular problems which have to be identified and dealt with. This practical guide provides some information which may be helpful in this new scenario. As more and more information becomes available, therapies and guidelines will need to be updated to provide the best care for all patients.

The health-care personal have to be aware of the cardiovascular manifestations of COVID-19 and the up-to-date management of both COVID and cardiology emergencies in the setting of COVID. They also need to be aware of what levels of PPE they need to wear in a different setting. They also have to be constantly retrained in the latest guidelines because the guidelines keep changing based on the latest information.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
World Health Organization. WHO Director-General's Opening Remarks at the Media Briefing on COVID-19. Available from: https://www.who.int/dg/speeches/detail/who-director-general-s-opening-remarks-at-the- media-briefing-on-covid-19-11-march-2020. [Last accessed on 2020 May 07].  Back to cited text no. 1
    
2.
COVID-19 Dashboard by the Center for Systems Science and Engineering (CSSE) at Johns Hopkins University (JHU)”. ArcGIS. Johns Hopkins University. [Last retrieved 2020 May 30].  Back to cited text no. 2
    
3.
Ministry of Health and Family Welfare, M.O.H.F.W. COVID-19 India. Available from: https://www.mohfw.gov.in. [Last accessed on 2020 May 30].  Back to cited text no. 3
    
4.
Zhou F, Yu T, Du R, Fan G, Liu Y, Liu Z, et al. Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: A retrospective cohort study. Lancet 2020;395:1054-62.  Back to cited text no. 4
    
5.
Xu Z, Shi L, Wang Y, Zhang J, Huang L, Zhang C, et al. Pathological findings of COVID-19 associated with acute respiratory distress syndrome. Lancet Respir Med 2020;8:420-2.  Back to cited text no. 5
    
6.
Xiong TY, Redwood S, Prendergast B, Chen M. Coronaviruses and the cardiovascular system: Acute and long-term implications. Eur Heart J 2020;41:1798-800.  Back to cited text no. 6
    
7.
Yu CM, Wong RS, Wu EB, Kong SL, Wong J, Yip GW, et al. Cardiovascular complications of severe acute respiratory syndrome. Postgrad Med J 2006;82:140-4.  Back to cited text no. 7
    
8.
Madjid M, Safavi-Naeini P, Solomon SD, Vardeny O. Potential effects of coronaviruses on the cardiovascular system: A review. JAMA Cardiol 2020;5:831-40.  Back to cited text no. 8
    
9.
Guo T, Fan Y, Chen M, Wu X, Zhang L, He T, et al. Cardiovascular implications of fatal outcomes of patients with coronavirus disease 2019 (COVID-19). JAMA Cardiol 2020;5:811-18.  Back to cited text no. 9
    
10.
Clerkin KJ, Fried JA, Raikhelkar J, Sayer G, Griffin JM, Masoumi A, et al. COVID-19 and cardiovascular disease. Circulation 2020;141:1648-55.  Back to cited text no. 10
    
11.
Fang L, Karakiulakis G, Roth M. Are patients with hypertension and diabetes mellitus at increased risk for COVID-19 infection? Lancet Respir Med 2020;8:e21.  Back to cited text no. 11
    
12.
Williams B, Zhang Y. Hypertension, renin-angiotensin-aldosterone system inhibition, and COVID-19. Lancet 2020;395:1671-3.  Back to cited text no. 12
    
13.
Kuster GM, Pfister O, Burkard T, Zhou Q, Twerenbold R, Haaf P, et al. SARS-CoV2: Should inhibitors of the renin-angiotensin system be withdrawn in patients with COVID-19? Eur Heart J 2020;41:1801-3.  Back to cited text no. 13
    
14.
Ferrario CM, Jessup J, Chappell MC, Averill DB, Brosnihan KB, Tallant EA, et al. Effect of angiotensin-converting enzyme inhibition and angiotensin II receptor blockers on cardiac angiotensin-converting enzyme 2. Circulation 2005;111:2605-10.  Back to cited text no. 14
    
15.
Mehra MR, Desai SS, Kuy S, Henry TD, Patel AN. Cardiovascular disease, drug therapy, and mortality in Covid-19. N Engl J Med 2020;382:e102.  Back to cited text no. 15
    
16.
Bean D, Kraljevic Z, Searle T, Bendayan R, Kevin O, Pickes A, et al. Angiotensin-converting enzyme inhibitors and angiotensin II receptor blockers are not associated with severe COVID-19 infection in a multi-site UK acute hospital trust. European Journal of Heart Failure. 2020;22(6):967-74.  Back to cited text no. 16
    
17.
de Abajo FJ, Rodríguez-Martín S, Lerma V, Mejía-Abril G, Aguilar M, García-Luque A, et al. Use of renin-angiotensin-aldosterone system inhibitors and risk of COVID-19 requiring admission to hospital: A case-population study. Lancet 2020;395:1705-14.  Back to cited text no. 17
    
18.
Li J, Wang X, Chen J, Zhang H, Deng A. Association of renin-angiotensin system inhibitors with severity or risk of death in patients with hypertension hospitalized for coronavirus disease 2019 (COVID-19) infection in Wuhan, China. JAMA Cardiol 2020 Apr 23;5(7):1-6.  Back to cited text no. 18
    
19.
Mancia G, Rea F, Ludergnani M, Apolone G, Corrao G. Renin-angiotensin-aldosterone system blockers and the risk of Covid-19. N Engl J Med 2020;382:2431-40.  Back to cited text no. 19
    
20.
Reynolds HR, Adhikari S, Pulgarin C, Troxel AB, Iturrate E, Johnson SB, et al. Renin-angiotensin-aldosterone system inhibitors and risk of Covid-19. N Engl J Med 2020;382:2441-8.  Back to cited text no. 20
    
21.
Zhang P, Zhu L, Cai J, Lei F, Qin JJ, Xie J, et al. Association of inpatient use of angiotensin-converting enzyme inhibitors and angiotensin II receptor blockers with mortality among patients with hypertension hospitalized with COVID-19. Circ Res 2020;126:1671-81.  Back to cited text no. 21
    
22.
Inciardi RM, Lupi L, Zaccone G, Italia L, Raffo M, Tomasoni D, et al. Cardiac involvement in a patient with coronavirus disease 2019 (COVID-19). JAMA Cardiol 2020;5(7):819-24.  Back to cited text no. 22
    
23.
Vaduganathan M, Vardeny O, Michel T, McMurray JJV, Pfeffer MA, Solomon SD. Renin-angiotensin-aldosterone system inhibitors in patients with Covid-19. N Engl J Med 2020;382:1653-9.  Back to cited text no. 23
    
24.
Chen C, Zhou Y, Wang DW. SARS-CoV-2: A potential novel etiology of fulminant myocarditis. Herz 2020;45:230-2.  Back to cited text no. 24
    
25.
Huang C, Wang Y, Li X, Ren L, Zhao J, Hu Y, et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet 2020;395:497-506.  Back to cited text no. 25
    
26.
Ruan Q, Yang K, Wang W, Jiang L, Song J. Clinical predictors of mortality due to COVID-19 based on an analysis of data of 150 patients from Wuhan, China. Intensive Care Med 2020;46:846-8.  Back to cited text no. 26
    
27.
Wang D, Hu B, Hu C, Zhu F, Liu X, Zhang J, et al. Clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus-infected pneumonia in Wuhan, China. JAMA 2020;323:1061-9.  Back to cited text no. 27
    
28.
Chen J, Wang X, Zhang S, Liu B, Wu X, Wang Y, et al. Findings of acute pulmonary embolism in COVID-19 Patients. Available at SSRN 3548771. 2020.  Back to cited text no. 28
    
29.
Danzi GB, Loffi M, Galeazzi G, Gherbesi E. Acute pulmonary embolism and COVID-19 pneumonia: A random association? Eur Heart J 2020;41:1858.  Back to cited text no. 29
    
30.
Xie Y, Wang X, Yang P, Zhang S. COVID-19 complicated by acute pulmonary embolism. Radiology 2020;2:e200067.  Back to cited text no. 30
    
31.
European Society of Cardiology. ESC Guidance for the Diagnosis and Management of CV Disease during the COVID-19 Pandemic. Available from: https://www.escardio.org/Education/COVID-19- and-Cardiology/ESC-COVID-19-Guidance. [Last accessed on 2020 Apr 28].  Back to cited text no. 31
    
32.
Guan WJ, Ni ZY, Hu Y, Liang WH, Ou CQ, He JX, et al. Clinical characteristics of coronavirus disease 2019 in China. N Engl J Med 2020;382:1708-20.  Back to cited text no. 32
    
33.
Huisman MV, Barco S, Cannegieter SC, Le Gal G, Konstantinides SV, Reitsma PH, et al. Pulmonary embolism. Nat Rev Dis Primers 2018;4:18028.  Back to cited text no. 33
    
34.
Konstantinides SV, Meyer G, Becattini C, Bueno H, Geersing GJ, Harjola VP, et al. 2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the European Respiratory Society (ERS): The Task Force for the diagnosis and management of acute pulmonary embolism of the European Society of Cardiology (ESC). Eur Respir J 2019;54(3):1901647.  Back to cited text no. 34
    
35.
Centre for Disease Control. Interim Infection Prevention and Control Recommendations for Patients with Suspected or Confirmed Coronavirus Disease 2019 (COVID-19) in Healthcare Settings. Available from: https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html. [Last accessed on 2020 May 07].  Back to cited text no. 35
    
36.
Ministry of Health and Family Welfare. Novel Coronavirus Disease 2019 (COVID-19): Guidelines on Rational use of Personal Protective Equipment. Available from: https://www.mohfw.gov.in/pdf/GuidelinesonrationaluseofPersonalProtectiveEquipment.pdf. [Last accessed on 2020 May 07].  Back to cited text no. 36
    
37.
Shi H, Han X, Jiang N, Cao Y, Alwalid O, Gu J, et al. Radiological findings from 81 patients with COVID-19 pneumonia in Wuhan, China: A descriptive study. Lancet Infect Dis 2020;20:425-34.  Back to cited text no. 37
    
38.
European Centre for Disease Prevention and Control. Infection Prevention and Control for the care of Patients with 2019-nCoV in Healthcare SettingsFirst update; 12 March, 2020. Available from: https://www.ecdc.europa.eu/sites/default/files/documents/COVID-19-infection-prevention-and-control- healthcare-settings-march-2020.pdf. [Last accessed on 2020 May 04].  Back to cited text no. 38
    
39.
European Society of Cardiology. Protecting Cardiologists during the COVID-19 Epidemic – Lessons from Wuhan, China. Available from: https://www.escardio.org/Education/COVID-19-and-Cardiology/protecting- cardiologists-during-the-covid-19-epidemic-lessons-from-wuhan. [Last accessed on 2020 May 04].  Back to cited text no. 39
    
40.
Liang T, Yu L. Handbook of COVID-19 Prevention and Treatment. China; 2020. Available from: https://www.researchgate.net/publication/339998871_Handbook_of_COVID-19_Prevention_and_Treatment. [Last accessed on 2020 May 07].  Back to cited text no. 40
    
41.
Zeng J, Huang J, Pan L. How to balance acute myocardial infarction and COVID-19: the protocols from Sichuan provincial people's hospital. Intensive Care Med 2020;46(6):1111-3.  Back to cited text no. 41
    
42.
Welt FG, Shah PB, Aronow HD, Bortnick AE, Henry TD, Sherwood MW, et al. Catheterization laboratory considerations during the coronavirus (COVID-19) pandemic: From the ACC's interventional council and SCAI. J Am Coll Cardiol 2020;75:2372-5.  Back to cited text no. 42
    
43.
Konstantinides SV, Meyer G, Becattini C, Bueno H, Geersing GJ, Harjola VP, et al. 2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the European Respiratory Society (ERS). Eur Heart J 2020;41:543-603.  Back to cited text no. 43
    
44.
Guglielmo M, Baggiano A, Muscogiuri G, Fusini L, Andreini D, Mushtaq S,et al. Multimodality imaging of left atrium in patients with atrial fibrillation. J Cardiovasc Comput Tomogr 2019;13(6):340-6.  Back to cited text no. 44
    
45.
Kirkpatrick JN, Mitchell C, Taub C, Kort S, Hung J, Swaminathan M. ASE statement on protection of patients and echocardiography service providers during the 2019 novel coronavirus outbreak: Endorsed by the American College of Cardiology. J Am Soc Echocardiogr 2020;33:648-53.  Back to cited text no. 45
    
46.
Colson P, Rolain JM, Lagier JC, Brouqui P, Raoult D. Chloroquine and hydroxychloroquine as available weapons to fight COVID-19. Int J Antimicrob Agents 2020;55:105932.  Back to cited text no. 46
    
47.
Gautret P, Lagier JC, Parola P, Hoang VT, Meddeb L, Mailhe M, et al. Hydroxychloroquine and azithromycin as a treatment of COVID-19: Results of an open-label non-randomized clinical trial. Int J Antimicrob Agents 22020;56(1):105949.  Back to cited text no. 47
    
48.
Wang M, Cao R, Zhang L, Yang X, Liu J, Xu M, et al. Remdesivir and chloroquine effectively inhibit the recently emerged novel coronavirus (2019-nCoV) in vitro. Cell Res 2020;30:269-71.  Back to cited text no. 48
    
49.
Yao X, Ye F, Zhang M, Cui C, Huang B, Niu P, et al.In vitro antiviral activity and projection of optimized dosing design of hydroxychloroquine for the treatment of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Clin Infect Dis 2020;71(15):732-739.  Back to cited text no. 49
    
50.
Smith T. COVID-19 Drug Therapy – Potential Options. Available from: https://www.elsevier.com/connect/coronavirus-information-center. [Last accessed on 2020 Mar 26].  Back to cited text no. 50
    
51.
Haeusler IL, Chan XH, Guérin PJ, White NJ. The arrhythmogenic cardiotoxicity of the quinoline and structurally related antimalarial drugs: A systematic review. BMC Med 2018;16:200.  Back to cited text no. 51
    
52.
Howard PA. Azithromycin-induced proarrhythmia and cardiovascular death. Ann Pharmacother 2013;47:1547-51.  Back to cited text no. 52
    
53.
Poluzzi E, Raschi E, Motola D, Moretti U, de Ponti F. Antimicrobials and the risk of torsades de pointes: The contribution from data mining of the US FDA Adverse Event Reporting System. Drug Saf 2010;33:303-14.  Back to cited text no. 53
    
54.
Kimani J, Phiri K, Kamiza S, Duparc S, Ayoub A, Rojo R, et al. Efficacy and Safety of azithromycin-chloroquine versus sulfadoxine-pyrimethamine for intermittent preventive treatment of Plasmodium falciparum Malaria infection in pregnant Women in Africa: An Open-Label, Randomized Trial. PLoS One 2016;11:e0157045.  Back to cited text no. 54
    
55.
Sagara I, Oduro AR, Mulenga M, Dieng Y, Ogutu B, Tiono AB, et al. Efficacy and safety of a combination of azithromycin and chloroquine for the treatment of uncomplicated Plasmodium falciparum malaria in two multi-country randomised clinical trials in African adults. Malar J 2014;13:458.  Back to cited text no. 55
    
56.
Yang T, Roden DM. Extracellular potassium modulation of drug block of I Kr. Circulation 1996;93:407-11.  Back to cited text no. 56
    


    Figures

  [Figure 1]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

Top
 
 
  Search
 
Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

 
  In this article
   Abstract
  Introduction
  Methodology
  Conclusion
   References
   Article Figures
   Article Tables

 Article Access Statistics
    Viewed111    
    Printed2    
    Emailed0    
    PDF Downloaded26    
    Comments [Add]    

Recommend this journal


[TAG2]
[TAG3]
[TAG4]