Box 1.

Summary of advice relating to cardiovascular disease management during COVID-19

Patients without COVID-19 but with cardiovascular disease
Services are being restructured to limit face-to-face contact and avoid non-urgent procedures
Virtual clinics will replace outpatients and only essential face-to-face appointments will continue
Elective cardiac procedures will be deferred or scheduled based on urgency
Referrals to outpatient services should continue, although appointments may be delayed
Coronary angiography in ACS will be performed or delayed according to clinical urgency (eg primary PCI performed in STEMI, delayed in NSTEMI with low risk features)
Optimisation of medications is key in ACS
PCI may be preferred over cardiac surgery in high-risk ACS with multivessel disease
Acute pacing will be available in most centres but reserved for high risk (eg high-grade AVB, severe symptomatic SND and long pauses)
Defibrillators (+/– CRT) will be reserved for secondary prevention (eg SCD survivors, ventricular arrhythmias with haemodynamic compromise)
Remote device checks and monitoring will be utilised where possible
Only urgent catheter ablations will be carried out (eg VT ablation in VT storm, pre-excited AF in WPW, atrial arrhythmias causing heart failure)
ACEi/ARBs should not be discontinued due to COVID-19 concerns
BNP testing in suspected heart failure can help prioritise patients needing urgent assessment
Differentiating COVID-19 symptoms from a presentation of CVD
Recognise that there is an overlap in clinical features of COVID-19 and cardiac diseases
Avoid (if possible) auscultation of the chest in patients with symptoms suggestive of COVID-19
Recognise that Brugada syndrome may be unmasked by fever in COVID-19, and although this is a rare condition there are important implications for management
The patient with COVID-19 and pre-existing CVD
There is a high prevalence of CVD in COVID-19 patients
CVD is associated with worse outcomes (ie increased need for intensive care, higher mortality)
The patient with COVID-19 who has developed cardiovascular complications
Heart failure is a common finding in patients with COVID-19, and carries a worse prognosis
Left ventricular systolic dysfunction may be pre-existing, or a result of COVID-19-induced myocarditis, or of inflammatory-mediated cardiomyopathy
Patients with left ventricular systolic dysfunction are at higher risk of needing mechanical ventilation
Elevated serum troponin and BNP confers a worse prognosis
Primary PCI remains the gold standard of care for STEMI in patients with COVID-19 but thrombolysis can be considered in selected cases
TTE can be considered in patients with COVID-19 but TOE should be avoided
Arrhythmias are common in COVID-19
PPM is generally deferred, but in unstable cases temporary pacing can be considered
Emerging drugs (eg lopinavir, hydroxychloroquine) carry pro-arrhythmia risks and may necessitate monitoring
  • ACEi = angiotensin converting enzyme inhibitor, ACS = acute coronary syndrome, AF = atrial fibrillation, ARB = angiotensin receptor blocker, AVB = atrioventricular block, BNP = brain natriuretic peptide, CRT = cardiac resynchronisation therapy, CVD = cardiovascular disease, NSTEMI = non ST elevation myocardial infarction, PCI = percutaneous coronary intervention, PPM = permanent pacemaker, SCD = sudden cardiac death, SND = sinus node dysfunction, STEMI = ST elevation myocardial infarction, TTE = transthoracic echocardiography, TOE = transoesophageal echocardiography, VT = ventricular tachycardia.