Table 2

Suggested CV surveillance tools and their potential findings in patients infected with COVID-19

MethodIn whom and how oftenPotential findingsSignificance
ECG
  • Baseline in all with evidence of moderate or severe COVID-19 infection

  • Any with pre-existing CV disease or high-risk factor burden

  • Those with arrhythmia

  • Marked cTn elevation

  • Typical ACS symptoms

  • Daily in those given hydroxychloroquinexr

  • ST-segment and T-wave changes

  • Reciprocal changes

  • Arrhythmias

  • Prolonged QT

Coronary angiography in those with reciprocal ECG changes and hs-Tn elevation particularly if progressive
Transthoracic echocardiography
Point-of-care approach useful (POCUS)
  • In those with moderate or severe COVID-19 disease and cTn, BNP, elevation or pre-existing disease combination with high inflammatory markers

  • Haemodynamic instability, suspicion of left ventricular or right ventricular dysfunction.

  • Pulmonary embolism

  • Dedicated echocardiography in significantly elevated troponin or ECG abnormalities and/or concern for congestive HF

  • Left ventricular dysfunction (diffuse or segmental)

  • Increased wall thickness (pseudohypertrophy-myocarditis)

  • Intracardiac thrombosis

  • Pericardial effusion

  • Reduced TAPSE and right ventricular function

  • Elevated right ventricular systolic pressures, Inferior vena caval distension without respiratory variation (not true for patients in ventilation)

  • Raised right ventricular filling pressures

  • Evidence of stress cardiomyopathy

Focused echocardiography should be performed only in those where management likely to be influenced
  • Limited studies to address specific clinical questions

  • Left ventricular hypertrophy and left ventricular dysfunction and pericardial effusion may indicate myocarditis

  • Combination of LUS congestion + high right ventricular filling pressures may signal imminent CV decline; consider ICU admission/intubation

MRI
criteria for inflammation or injury
(Lake Louise Consensus Criteria)
  • Those with inconclusive clinical and echocardiographic evidence of myocarditis

  • T1 and T2 -mapping sequences and T1 inversion recovery (STIR) sequences for myocardial interstitial oedema

  • Late gadolinium enhancement can be considered

 MRI may help confirm diagnosis in suspected or exclude in doubtful myocarditis patients, stress cardiomyopathy
Endomyocardial biopsy
  • Role not clearly defined yet

  • Differentiating direct viral myocardial involvement from secondary causes

  • New-onset HF of less than 2 weeks’ duration associated with a normal-sized or dilated left ventricle and haemodynamic compromise

  • Presence of viral particles within myocardium29

  • Identification of direct viral localisation in the myocardium

  • Identification of secondary immune effects

  • Assessment of response to drug therapy

Coronary CTDifferential diagnosis with ACS Non-obstructive lesions
Cardiology consult
  • Refractory arrhythmia

  • ACSs with evolving cTn’s and ECG changes

  • New onset of HF

  • Potential mechanical circulatory support

  • ACS, acute coronary syndrome; BNP, brain natriuretic peptide; cTn, cardiac troponins; CV, cardiovascular; HF, heart failure; hs-Tn, highly sensitive troponin; ICU, intensive care unit; LUS, lung ultrasound; POCUS, point-of-care ultrasound; TAPSE, tricuspid annular plane systolic excursion.