NICE guidelines for non-cardiologists on heart injury in COVID-19 patients

  • National Institute for Health and Care Excellence

  • curated by Dawn O'Shea
  • Clinical Guidance Summaries
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NICE has developed guidelines to help health care professionals who are not cardiology specialists to identify and treat acute myocardial injury (AMI) and its cardiac complications in adults with known or suspected COVID-19 but no known pre-existing cardiovascular disease. Here, Univadis provides a summary of the key recommendations.

General recommendations

  • Communicate with patients and support their mental well-being, signposting to charities and support groups where available.
  • Minimise face-to-face contact.
  • Advise patients to contact NHS 111 by phone or via the website for advice on COVID‑19.
  • For patients with known or suspected COVID‑19, follow government guidance on infection prevention and control.
  • If COVID‑19 is later diagnosed in a patient not isolated from admission or presentation, follow UK government guidance on management of exposed health care workers and patients in hospital settings.

Diagnosing AMI in patients with suspected or confirmed COVID-19

  • Be aware that AMI and its complications:
  • have signs and symptoms similar to respiratory complications of COVID-19,
  • were observed in 9.5% of all COVID-19 deaths in Italy, and
  • may develop at any stage of COVID-19.
  • Be aware that AMI in patients with COVID-19 includes:
  • acute coronary syndromes,
  • arrhythmias,
  • cardiac arrest,
  • cardiogenic shock,
  • cardiomyopathy,
  • heart failure,
  • myocarditis, and
  • pericarditis and pericardial effusion.
  • Symptoms suggesting AMI in patients with COVID-19 include:
  • chest pain,
  • palpitation,
  • severe fatigue, and
  • shortness of breath.

Diagnostic tests

  • In patients with symptoms or signs of AMI, measure high sensitivity troponin I (hs-cTnI) or T (hs-cTnT) and N-terminal pro B-type Natriuretic Peptide (NT-proBNP) and perform an electrocardiogram (ECG).
  • Use the following test results to inform a diagnosis:
    • evolving ECG changes suggesting myocardial ischaemia,
    • NT-proBNP level above 400 ng/L, and
    • high levels of hs-cTnI or hs-cTnT, particularly levels increasing over time.
  • Be aware that elevated troponin levels may reflect cardiac inflammatory response to severe illness rather than acute coronary syndrome.

Managing myocardial injury in patients with suspected or confirmed COVID-19

  • For all patients with suspected or confirmed AMI:
    • monitor in a setting where deterioration can be rapidly identified;
    • perform continuous ECG monitoring; and
    • monitor blood pressure, heart rate and fluid balance.
  • For patients with a clear diagnosis of AMI, seek specialist cardiology advice.
  • For patients with a high clinical suspicion of AMI but no clear diagnosis, repeat hs-cTnI or hs-cTnT and ECG daily and seek specialist advice.
  • Discuss the risks and benefits of treatment options with patients, families and carers.

Cardiac effects of COVID-19 therapies

  • Treatments such as azithromycin and hydroxychloroquine, may prolong QTc interval and lead to arrhythmia.
  • For recommendations on critical care, see the NICE COVID-19 rapid guideline: critical care in adults.
  • Stop critical care treatment when it is no longer considered able to achieve the desired overall goals.

Read more on Medscape UK.