COVID-19 and Cardiovascular Disease: Key Considerations for Cardiovascular Nurses
This article was co-written by Oluwabunmi Ogungbe, MPH, RN and Yvonne Commodore-Mensah, PhD, MHS, RN
Coronavirus disease 2019 (COVID-19) is an infectious disease caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Contrary to earlier reports that COVID-19 was mostly a respiratory disease, it is now well accepted that COVID-19 is a multi-organ system disease. COVID-19 affects the cardiovascular system and has major implications for the care of patients with cardiovascular disease (CVD).
Patients with pre-existing CVD and risk factors such as hypertension, diabetes, and obesity have higher morbidity and mortality from COVID-19.1,2 A meta-analysis of 1,527 patients with COVID-19 reported the prevalence of hypertension, diabetes, cardiovascular and cerebrovascular disease as 17.1%, 9.7%, and 16.4% respectively.3 With regards to risk-stratification, patients with cardiovascular conditions are at the highest risk for adverse outcomes and should be closely monitored.
Patients hospitalized with COVID-19 may develop Acute COVID-19 Cardiovascular Syndrome (ACovCS), characterized by multiple cardiovascular complications including myocarditis, cardiomyopathies, myocardial infarctions, hemodynamic instability, and ventricular arrhythmias.4 Although, the exact cause of this phenomenon is unknown, associations with microvascular injury, myocarditis systemic cytokine-mediated injury, or stress-related cardiomyopathy are suspected. Patients hospitalized with COVID-19 also experience coagulopathies characterized by elevations in fibrinogen and D-dimer levels and are at risk for venous thromboembolism.5
Since COVID-19 has been linked to CVD, guidance from the American College of Cardiology6 and the European Society of Cardiology7 is that CVD patients with COVID-19 be triaged based on disease severity and managed per hospital protocol. PCNA has also created a “COVID-19 Resources for Cardiovascular Nurses”8 webpage.
There are promising therapies to manage COVID-19, including antiviral agents, anti-inflammatory therapies, interleukin-6 inhibitors, and convalescent plasma.9,10 Remdesivir, a direct-acting antiviral drug is FDA-approved to treat COVID-19, through an Emergency Use Authorization based on preliminary results from the Adaptive COVID-19 Treatment Trial. In the study, participants who received Remdesivir had a 31% faster time to recovery compared to the control group (p<0.001).11 Since some of these therapies are under investigation, their cardiovascular safety remains unclear.
Management of acute cardiovascular complications remains unchanged for COVID-19 negative patients. However, nurses should remain vigilant when caring for patients with suggestive symptoms and in areas of high transmission. Usual care is recommended for CVD patients with two negative COVID-19 tests within 24 hours.12 The involvement of renin-angiotensin-aldosterone system (RAAS) antagonists’ in SARS-COV-2 pathogenesis is unclear. Several cardiovascular professional organizations have issued statements supporting the continued use of Angiotensin-converting enzyme Inhibitors and Angiotensin Receptor Blockers.
Patients with cardiovascular conditions are a high-risk group, and cardiovascular nurses should limit exposures to persons who may be infected with the virus or settings where physical-distancing is not enforced. Nurses should adhere consistently to standard practices like wearing masks outside the clinical setting. In the clinical setting, cardiovascular nurses should use appropriate personal protective equipment (PPE) in delivering care to patients with or without COVID-19. There have been reports of shortages of PPE, which places nurses and other healthcare providers at risk. Thus, cardiovascular nurses should be engaged in advocacy efforts to ensure a consistent supply of PPE, access to COVID-19 testing, and contact-tracing across the country to reduce the burden of COVID-19.
- Wu Z. Characteristics of and important lessons from the coronavirus disease 2019 (COVID-19) outbreak in china: Summary of a report of 72314 cases from the chinese center for disease control and prevention. JAMA. 2020. doi: 10.1001/jama.2020.2648 [doi].
- Mancia G, Rea F, Ludergnani M, Apolone G, Corrao G. Renin-angiotensin-aldosterone system blockers and the risk of covid-19. N Engl J Med. 2020;382(25):2431-2440. doi: 10.1056/NEJMoa2006923 [doi].
- Li B, Yang J, Zhao F, et al. Prevalence and impact of cardiovascular metabolic diseases on COVID-19 in china. Clin Res Cardiol. 2020;109(5):531-538. doi: 10.1007/s00392-020-01626-9 [doi].
- Hendren NS, Drazner MH, Bozkurt B, Cooper LT,Jr. Description and proposed management of the acute COVID-19 cardiovascular syndrome. Circulation. 2020;141(23):1903-1914. doi: 10.1161/CIRCULATIONAHA.120.047349 [doi].
- Klok FA, Kruip MJHA, van der Meer NJM, et al. Incidence of thrombotic complications in critically ill ICU patients with COVID-19. Thromb Res. 2020;191:145-147. doi: S0049-3848(20)30120-1 [pii].
- American College of Cardiology. COVID-19 clinical Guidance For the cardiovascular care team. https://www.acc.org/~/media/665AFA1E710B4B3293138D14BE8D1213.pdf. Updated 2020. Accessed August, 14, 2020.
- European Society of Cardiology. ESC guidance for the diagnosis and management of CV disease during the COVID-19 pandemic. https://www.escardio.org/Education/COVID-19-and-Cardiology/ESC-COVID-19-Guidance#p09. Updated 2020. Accessed August, 14, 2020.
- Preventive Cardiovascular Nurses Association. COVID-19 resources for cardiovascular nurses. https://pcna.net/covid-19-resources-for-cardiovascular-nurses/. Updated 2020. Accessed August, 14, 2020.
- Driggin E, Madhavan MV, Bikdeli B, et al. Cardiovascular considerations for patients, health care workers, and health systems during the COVID-19 pandemic. J Am Coll Cardiol. 2020;75(18):2352-2371. doi: S0735-1097(20)34637-4 [pii].
- Mehta P, McAuley DF, Brown M, et al. COVID-19: Consider cytokine storm syndromes and immunosuppression. Lancet. 2020;395(10229):1033-1034. doi: S0140-6736(20)30628-0 [pii].
- National Institute of Health. NIH clinical trial shows remdesivir accelerates recovery from advanced COVID-19. https://www.nih.gov/news-events/news-releases/nih-clinical-trial-shows-remdesivir-accelerates-recovery-advanced-covid-19. Updated 2020. Accessed August, 13, 2020.
- Ganatra S, Dani SS, Shah S, et al. Management of cardiovascular disease during coronavirus disease (COVID-19) pandemic. Trends Cardiovasc Med. 2020;30(6):315-325. doi: S1050-1738(20)30069-4 [pii].