3-26-20 Stanford CGR Presentation June-Wha Rhee, MD Sean Wu, MD Paul Cheng, MD Han Zhu, MD Stanford University “Cardiac Complications of COVID-19” - Shared screen with speaker view
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How do we really know that people with CAD have a higher risk of contracting COVID-19? It is hard to know the denominator of all who are infected.
Agree. They may just have more severe COVID disease and therefore are more likely to get tested.
I agree with Dr. Maron, all we have are association with worse outcome, but it may well be capturing another confounder
Published data have not even adjusted for other risk factors, though there are some preprints on Rxiv suggesting CVD risk factors like HTN carrying independent risk on top of age..etc.
For potential increase risk of getting infected in CAD patients, it would be hard without widespread testing with is not currently available. Maybe something that can be looked into when we have enough capacity for testing
For the Diamond princess, where everyone is tested, may be a good place to look.
Highly doubt CAD puts people at higher risk of contracting the virus — not very biologically plausible. Almost certainly comes from association with more serious clinical course/worse outcomes.
agree with Ron
In China, especially in Wuhan area, smoking (especially in men) is still extremely prevalent. So more CAD, poor lung function, high mortality
Any data to suggest chronic carriers? Little symptoms but can continue to infect others.
in Italy 55% of men smoke as opposed to few women. might explain gender differences in outcomes.
Could study this in the Telluride, CO population, where they are testing every person in the town regardless of symptoms. Though their + covid #s are probably quite low at this point.
Germany CFR 0.3%
It will be important to obtain any vaping history in all patients who test + for COVID-19 especially in the younger population that are presenting with symptoms.
Any data as to the explanation of why children and young adults seem to have a milder course when infected vs. adults? Some variation in receptor expression in the lung?
There was a report of re-infection which raised concerns regarding possibility of poor immune response against this virus, however, this has not been supported anywhere else. Serological assays has been developed to test post-exposure individual which says immune response is robust and likely to not have chronic carrier with active viral shedding
No existing evidence that ACE2 expression is different in children vs. adult.
Should health care providers be on prophylactic medications to lower the risk of becoming infected, and eventually becoming ‘super spreaders’?
No current recommendation for prophylactic treatment to prevent getting infected in HCw
No, I don’t that is warranted at this time.
No good mechanistic explanation or evidence on why kids barely effected relative to adults
how about in Italy? Over 5K healthcare providers are infected??
Is there any benefit of obtaining baseline and surveillance echocardiograms in all patients who are COVID+ and lower threshold for starting inotropic support?
Re: prophylaxis, there is a post-exposure prophylaxis study being conducted by U Minnesota for healthcare workers I believe
No evidence to support the echo/inotrope based approach. I would be very hesitant to start inotropes early unless indicated by hemodynamics. Would be good to have clear data on a cohort getting serial echos.
is there any data that patients with cad have regional wall motion abnormality in regions consistent with their cad rather than global dysfunction?
have not seen any report of regional WMA and co-existing CAD with COVID. Only global WMA so far
Any concern for pro thrombotic effects of IVIG
Any data on ACEI and COVID-19 risk?
RASS inhibitor info about to be presented…
Sean is about to discuss soon, but basically no.
How about Vit C? Any role?
it seems like based upon the mechanistic slides re: ACE receptors and Rx, this might be a good clinical trial proposal for us?
Some report from Chinese regarding vitamin C high dose treatment. No data on outcome.
I feel like vitamin C comes up all the time but hasn’t born out results
Should we be wearing N95 mask for all emergent procedures (STEMI, Temp wire…) on patients with unknown covid status coming through the ED?
1) is the rates of cardiac injury similar to what we see in other viral pneumonias
2) any risk of pro thrombotic issues w/ IVIG
anecdotal evidence re Statin therapy ????
Excellent GR! Can your slides be made available for sharing with those unable to join today?
3) there are anecdotal report of SCD even in younger non comorbid conditions as well as animal data showing long qtc w/ corona infection. Any thoughts?
No data seen in COVID-19 and IVIG treatment for pro thrombosis but is certainly a risk given the report of microthrombi in COVID pt
Yes will make slides available
Not seen a comparison of cardia complication frequency with flu or other viral illness
In Influenza, there is a even higher rate of troponin elevation, and is thought to be associated with increased MIs.
Not a lot of data of QT prolongation with COVID-19 infection alone. QT can be prolonged, and deep T wave inversions can be seen in myocardial injury situations
Bill, how are you triaging your TAVRs?
Have not seen discussion of statin use in COVID - other than potential concern for liver dysfunction in COVID which discontinuation is recommended
Cath lab = negative pressure?
Decision on PPE use has been institutional dependent given the shortage - quite a wide range observed
There have been reports of negative tests x1 or x2 with subsequent SARSCOV2 test positivity, Se: 60-70%
any CMR data?
Dr. Megha Agarwal’s iPhone XS Max
what is the false negative rate of US based testing for c19
Yes sensitivity is particularly problematic for nasopharyngeal samples
No CMR performed yet
can the panelists discuss their ECMO indications/experience? chinese experience was very selective and it remains a very difficult subject of who gets it. resource allocation obviously big factor. several cases across LA are on ECMO at different hospitals, and my understanding is that does not appear to be beneficial by the time multi organ failure is present.
I m missed a few of the criteria she mentioned to prompt tte. Did someone catch all fo them?
She is list the ASE guideline just released - may want to check there
Still doing TAVRs in patients with significant symptoms, LV dysfunction, recent hospitalization. Hard to find elective TAVR, but if patient has normal EF, milder symptoms and prefers to wait, we are postponing judiciously
Question 3 is on LV dysfunction management. Ron may get into ECMO question
Great Grand Rounds! Outstanding collection of recent publications and data in such a short time. Is there any role for NT-proBNP as a prognostic marker and as screening tool for cardiac MRI or echo?
thanks! great presentations!
Phenomenal presentation--thanks for doing this. The ASE COVID-19 link is here--https://www.asecho.org/wp-content/uploads/2020/03/ASE-COVID-Statement-FINAL.docx3-25-20-003.pdf
There is a preprint on prognostic value of NT-ProBNP, https://www.medrxiv.org/content/10.1101/2020.03.07.20031575v1. small study, but associated with worse outcome like troponin, with the same caveats
Trish, we don’t have dedicated COVID MR scanner yet.
New ACC guidance document on deferring non-urgent cardiovascular testing and procedures during the COVID-19 pandemic--https://www.acc.org/latest-in-cardiology/articles/2020/03/24/09/42/general-guidance-on-deferring-non-urgent-cv-testing-and-procedures-during-the-covid-19-pandemic
NT-ProBNP is being used as screening for LV dysfunction before getting echo due to risk of healthcare worker exposure. There is a ICU order template at Stanford being developed for COVID reflecting this as a screening tool. Nothing on NT-proBNP as prognostic marker just yet
Thank you for an excellent grand rounds.What are your thoughts on cardiac biopsy and helping to decide on therapy?
I would not pursue cardiac biopsy routinely. Too high a rate of false negatives even with true myocarditis, and just add more exposure to those in the lab, etc. If a compelling history like in the 37 y.o. patient in the case report would empirically treat, otherwise wouldn’t. In a really tough case could consider imaging like MRI, but again, have to be thoughtful about exposures to equipment/staff.
Would be great to have the data, but unfortunately, because it would require close exposure to a number of staff and operators, and not clear how it would change treatment, would not recommend.
An interesting pre-print article about the prognostic value of nt-probnp in covid-19 - https://www.medrxiv.org/content/10.1101/2020.03.07.20031575v1.full.pdf+html
Bill - are we still avoiding outpatient caths unless urgent?
Great presentation. Thanks for educating us. Are there any data that COVID phenotypes, and particularly cardiovascular manifestations, vary with region? Or are they evolving over time in the pandemic?
Most of the Chinese autopsy data in heart showed endothelial damage in the small vessels, no clear evidence of myocarditis. So need for biospies is low
Thanks for this awesome presentation. Best wishes to all. Jane Wilcox-Northwestern
Most data are coming out from China but as Italian’s reports their experiences, we may have something to say about regional CV event/outcome differences
Great GR! Any comment about NSAIDs as a possible risk factors for COVID19 infection/ severe infection?
Yes, All elective caths have been cancelled
Italian experience has emphasized prone positioning. Can you speak to the logistics of prone positioning and infectious concerns.
Do we know if there are various strains of the virus, some more virulent vs. others that can explain the variation in presentations?
Are there recommendations regarding use/timing/withholding ACI/ARBs in non-shock COVID pts with LV dysfunction
There are quite a large number of family members in the SARS-CoV tree. Don’t know the degree of their pathogenesis until one of them jump over to human
Hi Karis!! (Junes baby)
No 100% clear answer on the ACEi/ARB question posed. If they have baseline LV dysfunction and aren’t hypotensive I would likely continue to avoid taking them off their useful baseline Rx, but obviously low threshold to stop if BPs sag.
Cute baby! Amazing how you are leading this seminar while waking up at 1 and 3 am every night!
For nt pro bnp and tn routine screening. What do you think of using this screening for hospitalized pts to triage telemetry
thank you to all presenters. very helpful and comprehensive. stay well all.
Will the recording of this excellent meeting be available today, and will you send to us the URL?
Any comment about NSAIDs? I may have missed if this was answered
would someone be able to address sensitivity of our test and false negatives?
No good data on NSAIDs really, not even anything observational …all speculative.
We will make the link to this recording available. Will distribute via listserv - please share to colleagues externally.
Thank you all for being dedicated caregivers and serving your communities and patients
Re Chad: Don’t know about ours, because we don’t have a good enough gold standard. Certainly nasal sample RT-PCR problematic. Misses a lot of pt with positive pulmonary findings in this one center study published in radiology https://pubs.rsna.org/doi/full/10.1148/radiol.2020200432
Chad, that question was addressed at medicine grand rounds yesterday, if you want to look at that presentation
This presentation will be posted on the Stanford CME website
Gerilynn Schott, NP (Arrhythmia)
Thanks for great presentations.
thank you !