The role of cardiac imaging in hospitalized COVID-19–positive patients

Tom Kai Ming Wang; W.H. Wilson Tang; Scott D. Flamm; Brian Griffin; Siddharth Dugar; Richard A. Grimm; Deborah H. Kwon

doi:10.3949/ccjm.87a.ccc020

Article Figures & Data

Tables

View popup

TABLE 1

Suggested cardiac imaging tests by cardiovascular scenarios for hospitalized COVID-19 patients

Key questions before ordering imaging for ‘acute phase’ 1) What is the clinical concern, and will the findings result in substantial acute change in management? 2) Will the benefits of cardiac imaging outweigh the risk of potential exposure healthcare workers and nosocomial spread of virus? 3) Are there alternative, lower-risk options with sufficient accuracy? 4) Can cardiac imaging be deferred until infectious risks have been mitigated?
	Acute myocardial injury	Chest pain with or without electrocardiographic changes	Decompensated heart failure or acute hypoxia	Suspected infective endocarditis
Clinical and biomarker data to guide the need for acute cardiac imaging	Pattern of troponin elevation and severity of acute lung injury pattern	Risk stratification of coronary heart disease, troponin criteria	Established cardiovascular disease, symptoms and signs of heart failure. NT-proBNP and troponin levels	Risk stratification, bacteremia organism, need for surgery
Determinants for cardiac imaging: ‘acute phase'	Location of patient Emergency department or intensive care unit: cPOCUS Regular nursing floor: TTE (if cPOCUS unavailable)	STEMI: Urgent invasive coronary angiography (defer TTE), thrombolysis (do TTE) Other acute coronary syndromes or high risk: TTE/cPOCUS Submassive pulmonary embolism on CTA: Assess right ventricle by TTE/cPOCUS	Medically refractory cardiogenic shock: TTE/cPOCUS, CCTfor refractory atrial fibrillation requiring direct current cardioversion, invasive coronary angiography for patients with high suspicion of severe coronary artery disease Submassive pulmonary embolism on CTA: Assess right ventricle by TTE/cPOCUS	Discuss with infectious disease specialist if imaging would change treatment (if yes, TTE; if no, defer imaging) TTE positive: consult infectious disease service to determine need for further imaging
Patients with cardiovascular complications of COVID-19 should return for outpatient follow-up 4-6 weeks. Strategies for determining the need for PPE/repeat testing in the convalescent phase are to be determined.
Cardiac imaging: ‘convalescence phase' follow-up	Intermediate risk: Stress TTE, NUC, CMR Low risk: TTE ± CMR	STEMI follow-up: TTE Intermediate risk: Stress TTE, NUC, CMR or CCT Low risk: TTE ± CMR	TTE ± CMR Consider coronary CTA for patients with intermediate-low likelihood of severe coronary artery disease	Clinical deterioration: TTE ± TEE Clinically well Follow-up with infectious disease specialist and cardiologist to determine need for follow-up imaging

CCT = cardiac computed tomography, CMR = cardiac magnetic resonance imaging, cPOCUS = cardiac point-of-care ultrasonography, CTA = computed tomographic angiography, NUC = nuclear imaging, NT-proBNP = N-terminal pro-B-type natriuretic peptide, STEMI = ST-elevation myocardial infarction, TTE = transthoracic echocardiography.