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This article highlights some important issues referring to the NICE guidance published more than a week ago, and I was expecting to see some reactions to this article, however, let me put mine.
I wish to comment about the cardiovascular aspect of the guidance. It is evident that the NICE has mainly focused on the acute management setting of the covid-19 patients who are under hospital or similar care and would have rapid access to local cardiology review for appropriate support.
However, the cardiovascular complications of covid-19 could be a bigger issue outside the acute care setting, among a large number of unknown covid-19 exposed aysmptomatic and spontaneously recovered patients including those discharged from hospital after recovery from mild symptoms. The fundamental question is, if the pathophysiological mechanism of covid-19 has an underlying trigger factor for cardiovascular complications, then could it be already active in any covid-19 survived person with various degree of severity that is yet to be known?
If that is the case, then there could be a large section of covid-19 exposed asymptomatic population with silently progressing cardiovascular disease, awaiting symptoms or acute cardiac events in future. Particularly as we do not know why effect of covid-19 could be so severe with rapid deaths in some, but little or no symptoms in others with the same disease exposure, in otherwise healthy people?
There are number of recent rapid research publications on covid-19 talking about critical and severe cardiovascular complications and sudden deaths, although research in this area still long way to go. Currently NICE guidance, European cardiac society and the other informative sources suggest cardiovascular investigation at acute care stage, to reduce risk of fatality. However cardiovascular complications could occur with far more severity beyond acute care setting, and long term effect should also be considered, as much as the long term neurological impact of covid-19 is unknown.
Published information shows blood coagulation defect is a critical mortality factor and micro clots have been found in multiple pulmonary vascular fields in covid morbid patients https://onlinelibrary.wiley.com/doi/abs/10.1111/bjh.16749 .
Cardiovascular complications of covid-19 have been reported as myocardial injury, myocarditis, acute myocardial infarction, heart failure, dysrhythmias, and venous thromboembolic events, and angiotensin-converting enzyme 2 (ACE2) mechanism was thought to be another trigger factor in causing critical illness. https://www.ajemjournal.com/article/S0735-6757(20)30277-1/pdf .
It is therefore plausible that the micro clot mechanism might be playing silently in covid-19 affected population before manifestation of cardiovascular symptoms or complications. However the challenge is, how to identify micro clot in myocardial ischaemia where main coronaries could be entirely normal on invasive cardiac investigations. This will demand non invasive tests and advance cardiac imaging to investigate covid-19 affected population who still might be at risk of serious future cardiac events.
This means large scale non-invasive cardiac investigations may be required for all covid-19 exposed recovered as well as asymptomatic population with positive covid test or antibody test. Because if a basic pathological mechanism of covid-19 is to impair the coagulation pathway to produce micro clots then that can silently progress and cause severe cardiac events at a sooner or later stage. This is a big task and no doubt this will need a well thought strategic planning. However, so far it appears that it is a new chapter for cardiology teaching that covid-19 should be included in the cardiac history taking questionnaires in the cardiology textbooks and for the textbook writers there is still much to be learnt.
Competing interests:
No competing interests
02 May 2020
sisiresh chakrabarty
consultant cardiologist and clinical examiner King's college London
Consultant Cardiologist, London, harley street. Clinical Examiner, Medical Education and Examination faculty, King’s college London University Medical School
Cardiovascular risk and investigation for Covid-19 affected asymptomatic and survived population
Dear Editor
This article highlights some important issues referring to the NICE guidance published more than a week ago, and I was expecting to see some reactions to this article, however, let me put mine.
I wish to comment about the cardiovascular aspect of the guidance. It is evident that the NICE has mainly focused on the acute management setting of the covid-19 patients who are under hospital or similar care and would have rapid access to local cardiology review for appropriate support.
However, the cardiovascular complications of covid-19 could be a bigger issue outside the acute care setting, among a large number of unknown covid-19 exposed aysmptomatic and spontaneously recovered patients including those discharged from hospital after recovery from mild symptoms. The fundamental question is, if the pathophysiological mechanism of covid-19 has an underlying trigger factor for cardiovascular complications, then could it be already active in any covid-19 survived person with various degree of severity that is yet to be known?
If that is the case, then there could be a large section of covid-19 exposed asymptomatic population with silently progressing cardiovascular disease, awaiting symptoms or acute cardiac events in future. Particularly as we do not know why effect of covid-19 could be so severe with rapid deaths in some, but little or no symptoms in others with the same disease exposure, in otherwise healthy people?
There are number of recent rapid research publications on covid-19 talking about critical and severe cardiovascular complications and sudden deaths, although research in this area still long way to go. Currently NICE guidance, European cardiac society and the other informative sources suggest cardiovascular investigation at acute care stage, to reduce risk of fatality. However cardiovascular complications could occur with far more severity beyond acute care setting, and long term effect should also be considered, as much as the long term neurological impact of covid-19 is unknown.
Published information shows blood coagulation defect is a critical mortality factor and micro clots have been found in multiple pulmonary vascular fields in covid morbid patients https://onlinelibrary.wiley.com/doi/abs/10.1111/bjh.16749 .
Cardiovascular complications of covid-19 have been reported as myocardial injury, myocarditis, acute myocardial infarction, heart failure, dysrhythmias, and venous thromboembolic events, and angiotensin-converting enzyme 2 (ACE2) mechanism was thought to be another trigger factor in causing critical illness. https://www.ajemjournal.com/article/S0735-6757(20)30277-1/pdf .
It is therefore plausible that the micro clot mechanism might be playing silently in covid-19 affected population before manifestation of cardiovascular symptoms or complications. However the challenge is, how to identify micro clot in myocardial ischaemia where main coronaries could be entirely normal on invasive cardiac investigations. This will demand non invasive tests and advance cardiac imaging to investigate covid-19 affected population who still might be at risk of serious future cardiac events.
This means large scale non-invasive cardiac investigations may be required for all covid-19 exposed recovered as well as asymptomatic population with positive covid test or antibody test. Because if a basic pathological mechanism of covid-19 is to impair the coagulation pathway to produce micro clots then that can silently progress and cause severe cardiac events at a sooner or later stage. This is a big task and no doubt this will need a well thought strategic planning. However, so far it appears that it is a new chapter for cardiology teaching that covid-19 should be included in the cardiac history taking questionnaires in the cardiology textbooks and for the textbook writers there is still much to be learnt.
Competing interests: No competing interests