COVID-19

• It is ten times more deadly than seasonal flu
• Contact with a person for a short time or with a contaminated surface may lead to infection.
• Common symptoms are fever, cough and shortness of breath
• Those above 60 years and those with chronic disease are more vulnerable, but young healthy individual can be infected as well.
• Wearing a mask decrease the risk of transmission by five folds. Both cases and cases should wear a mask
• Keep away from a suspect by at least 2 meters.
• Alcohol based hand rub are helpful
• Remdesivir is recommended in Canada (not available in Egypt?).
• A vaccine will not be available for several months (may be a year).

Etiology:
A novel strain of corona virus (largest size RNA): Wuhan Dee 2019.

Risk factors:

  • Old age.
  • Male gender.
  • Chronic pulmonary disease.
  • Cardiovascular disease.
  • Cerebrovascular disease.
  • Diabetes mellitus.
  • Pregnancy.
  • Disposal:
  • 80% do not require hospitalization.
  • 10-20% need admission to ICU
  • 3-10% requires intubation.
  • 2-5% die.

Molecular basis of COVID-19 infection and site of action of proposed drugs:

Stages of the disease:

  • Replicative stage: Innate immunity fails
  • Adaptive immunity stage: leads to falling virus load, but liberation of cytokines that damage tissues, so patient improves for several days then deteriorate suddenly.
  • Cytokines storm: due to exuberant cytokine reaction. Features of bacterial sepsis occurs.
  • ARDS: occurs due to direct virus damage.

Clinical features:

  1. Fever: 43-98% of cases. Absence of fever dose not exclude the diagnosis.
  2. Cough
  3. Shortness of breath.
  4. Nausea and vomiting
  5. Silent hypoxemia (especially in the elderly)
  6. Pharyngitis and tonsils enlargement (2%).
  7. Cardiomyopathy and troponin elevation.


Investigations:

  1. • CBC: Lymphopenia (80%), thrombocytopenia (nearly < 100%).
  2. • DIC may occurs.
  3. • CRP: if normal consider non-COVID etiology.
  4. • Procalcitonin: normal- elevation. It suggests superimposed bacterial infection.
  5. • Chest X ray and CT:
  6. • Ground glass opacities, predominantly perihilar and basal. Pleural effusion uncommon, And
  7. • CT sensitivity is 86% in patients with respiratory symptoms. Abnormality may appear before symptoms.

Diagnosis:


• RT-PCR of a nasopharyngeal and oropharyngeal swab; sensitivity is 75%. A single negative result dose not exclude the diagnosis. If the suspicion is high repeat the sample after several days.
• A simple point -of-care immunoassay to detect IgG and IgM antibody against CoV-2 infection in human blood will soon be available as “ Artron rapid test kit”. Sensitivity and specificity are 90% each and results are available in 15 minutes.
• If PCR for other respiratory virus is positive the suspicion of COVID-19 is reduced substantially.
• Conventional viral panel (including corona viruses) do not work for COVI-19.
• CT may show evidence of the disease before PCR positivity.
Proposed diagnostic criteria:
• Epidemiological: contact with confirmed or suspected cases.


Clinical


o Fever + respiratory symptoms
o Imaging features (CXR and CT)
o Lymphopenea


Diagnosis:


o epidemiological + 2 clinical criteria
o or 3 clinical criteria.
Confirmation of diagnosis:
• Positive RT-PCR: lower respiratory samples increase sensitivity.
• Viral specific Ig M within 3-5 days.
• Four-fold rise in Ig G antibody in acute or recovery phase.


Impending critical cases:


• Progressive decrease in lymphocytes.
• Progressive elevation in inflammatory markers.
• Progressive elevation of serum lactate.
• Rapid progress in radiological lung infiltrates (sub-pleural opacity moves centrally).

Infection control measures:


• Use N 95 respirators.
• Use negative pressure rooms.
• Video guided laryngoscopy (preferred over direct laryngoscopy).
• Intubation by the most expert.
• Obtain endotracheal aspirate for testing.
Treatment
• Patients with mild symptoms should isolate themselves at home and do the following for one week (80% of cases):
• Drink enough water to have pale white urine.
• Get plenty of rest and avoid strenuous activity.
• Get paracetamol for fever and pain.
• Get cough suppressant for cough.
• Honey and lemon may improve sore throat.

• If symptoms are not improving after several days: seek medical advice. 20% requires hospitalization and 5% requires ventilation.

Proposed drugs:


• Chloroquine phosphate 500 mg bid for 10 days.
• Plaquenil 200 mg tds for 10 days
• Zithromycin 500mg on day 1 then 250mg /d for 5 days for suspected superimposed bacterial infection elevated procalcitonin).

• Hemodynamic support: for shocked patients (rare).
• Conservative fluid administration (saline 0.9%). Avoid liberal fluid administration (ARDS deteriorate).
• Norepinephrine is the first line vasoactive agent.
• In patients with cardiac dysfunction add Dobutamine rather than increasing norepinephrine.
• Target mean arterial blood pressure of 60-65 mm Hg.
• For refractory shock add hydrocortisone 200 mg/day IV
• Monitor skin temperature, capillary filling time and serum lactate.

• Respiratory support:
• Start supplemental oxygen if arterial oxygen saturation < 90% and maintain it not higher than 96%. • If insufficient, use high flow nasal oxygen. • If insufficient, try non-invasive positive pressure ventilation (NIPPV) with close monitoring of deterioration of respiratory failure. • If insufficient, early intubation. • For mechanical ventilation: o Vt 4-8 ml/Kg predicted body weight. o Plateau pressure < 30 cm/H2O for ARDS. o Driving pressure is not very high. o PEEP > 10 for ARDS (watch for barotrauma).
o Prone ventilation for 12-16 h for moderate to severe ARDS.
o Neuromuscular blockade for moderate to severe ARDS.
o Recruitment maneuvers may be needed.
o A trial of pulmonary vasodilator may be added.
o Systemic steroid for refectory cases.
• For cytokines storm: plasma exchange.
• ECMO for refractory hypoxemia.
• Empirical antibiotics (or based on microbiology result)
• Permissive hypercapnia (PH 7.1 – 7.15).
• Dialysis may be needed for renal failure.

COVID-19 for the cardiologist:

• Patients with cardiovascular disease are particularly susceptible for COVID-10 (10% of patients-50% mortality).
• ACE II receptors expressed by the heart and the alveoli are receptors for the virus. ACEI increases expression of this receptor, so increase susceptibility for infection, but do not stop them (recommendation of ESC).
• Decompensated heart failure, type II MI and myocarditis all have been reported.
• Unless full professionals’ protection is available, activate thrombolysis as an alternative to primary PCI (20% are health pronless with 10% mortality)
• Emergency telephone consultation for follow up when you feel them satisfactory.

Minimizing CPVID-19 exposure
Key consideration for cardiovascular disease providers

Overall goals:


Provide high quality care for patients with cardiovascular disease while minimizing infection risk for health care providers.

Procedural cardiology (interventional/electrophysiology/cardiac surgery):
• Cancel elective procedures.
• Minimize staffing in elective/emergency cases.
• Use negative pressure catheterization lab/operating rooms for urgent procedures.
• Consider fibrinolysis is case PCI is not feasible.

Cardiac critical care:


• Wear appropriate PPE according to institutional/ national/ international guidelines.
• Use airborne PPE with intubation and ACLS.
• Favor external compression device for CPR.

Echocardiography:


• Cancel elective procedures.
• Use bedside studies.
• Clean the machines and probes appropriately.
• Shorten exam length (fewer views).
• Use airborne PPE wit TEE.

Outpatient cardiology:
Cancel in-person consultation.
Utilize telehealth.

Cardiology teaching service:
Minimize non-essential staff (medical student).
Avoid large group rounds.
Develop over -the- phone rounds.


Copied From
Prof. Dr. MOHAMED ELGUINDY

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