| Ischaemic heart disease, myocarditis, myocardial injury |
| NSTEMI |
-
•
Check ECG and troponin if clinical suspicion of acute coronary syndrome (ACS)
-
•
Guideline directed medical therapy: aspirin, heparin, statin, beta blocker (if no bradycardia or cardiogenic shock)
-
•
Assess drug interaction of antiplatelet or anticoagulants
-
•
Cardiac catheterisation if high clinical suspicion of acute coronary occlusion
-
•
Coronary CT angiogram in haemodynamically stable NSTEMI
|
| STEMI |
-
•
Activate STEMI team per hospital protocol
-
•
Primary PCI for STEMI, thrombolytic therapy is controversial, use for low risk STEMI only if interventional cardiologist unavailable
-
•
Bedside echocardiogram if any clinical uncertainty
-
•
If no angiographic disease- monitor and treat myocarditis sequalae-heart failure; arrhythmia; thromboembolism and risk factor modification.
|
Myocardial injury
Myocarditis
Stress induced Cardiomyopathy |
-
•
Echocardiogram to assess LV function
-
•
Troponin trend to differentiate from Type I MI and assess prognosis along with BNP
-
•
Monitor for arrhythmia, consider EP consult if malignant arrhythmia
-
•
Inotropes and vasopressor support if haemodynamic instability with LV dysfunction.
-
•
Discuss antiviral and anti-inflammatory therapies approved to use.
-
•
Guideline directed medical therapy for cardiomyopathy
-
•
Exercise limitation for 3–6 months to prevent sudden cardiac death.
|
| Cardiac arrest |
-
•
Address goals of care early and periodically in all patients
-
•
Follow standard ACLS protocol
-
•
Consider mechanical CPR device if available
-
•
Use proper PPE per hospital protocol prior to initiating resuscitative efforts
-
•
Minimise code team size to prevent exposure to health care providers
|
| Heart failure and cardiogenic shock |
| Heart Failure |
-
•
BNP, troponin and echocardiogram to assess new onset HF
-
•
Telemetry for arrhythmia detection and monitoring
-
•
Standard HF management with daily weight, intake/output, diuresis, monitoring electrolytes and renal function
-
•
Limited fluid and blood product administration due to high risk of cardiopulmonary decompensation. Concentrate drips when able.
-
•
Avoid nonsteroidal anti-inflammatory agents
-
•
Continue ACEI/ARB/ARNI in otherwise stable patients who are at risk for, being evaluated for, or with Covid-19 unless hypotensive or renal failure.
-
•
Coronary CT angiogram for ischemic workup for new LV dysfunction if no ongoing ischaemia.
-
•
Cardiac catheterisation if HF suspected due to acute coronary syndrome.
|
| Shock |
-
•
SBP<90 for >15 mins with impaired organ perfusion, Urine output <30 m/hr.
-
•
Recognise delayed presentation of mechanical complications of myocardial infarction or peritonitis from bowel ischaemia related to low perfusion state.
-
•
Check mixed venous saturation to differentiate different types of shock.
-
•
Conservative fluid resuscitation, crystalloid preferred over colloid.
-
•
Norepinephrine to stabilise shock; transition to inotrope when clinically indicated.
-
•
Inhaled pulmonary vasodilators (INO preferred) should only be administered through a closed system to prevent risk from aerosolisation.
-
•
Evaluate alternate aetiologies of shock if haemodynamics not improving.
-
•
Discuss with interventional cardiology regarding activating shock team.
-
•
ECMO and mechanical circulatory support device in highly selected cases.
|
Transplant patient
Immunosuppression |
-
•
Discuss with heart transplant or cardiology team regarding reducing immunosuppression especially anti metabolites due to risk of infections.
-
•
Stress dose steroids for adrenal insufficiency for those on chronic steroids
|
| Arrhythmia |
| Prolonged QTc |
-
•
Telemetry monitoring and at least daily QT assessment
-
•
EP evaluation if QTc >450 msec in the absence of bundle branch block or >500 with bundle branch block if being started on antiarrhythmic or other QT prolonging medication.
-
•
Monitor electrolytes; Keep K >4.5, Mg >2.2
-
•
Monitor for QT prolongation if on QT prolonging medications
-
•
QTc=QT/√RR interval (in sec, Bazett correction). QTc will approximately be equal to QT if HR 60–70 bpm.
Key thresholds:
-
•
If QTc ≥470 ms in males and ≥480 ms females but <500 ms: close surveillance and stop QT prolonging medications
-
•
If QTc >500ms or >550 ms with BBB or increase in QTc >60 ms after drug initiation: place pacer pads, stop QT prolonging medication and maintain HR >80 bpm with isoproterenol or dobutamine.
|
Polymorphic VT
Sustained VT
Ventricular fibrillation
Torsades de Pointes (TdP) |
-
•
Advanced cardiac life support protocol if haemodynamic compromise
-
•
Follow guideline recommended antiarrhythmic therapy for specific conditions. Discussion with cardiology/electrophysiology team.
-
•
Amiodarone bolus 150 mg IV in non-code setting; Isoproterenol + Lidocaine or temporary pacing if bradycardia induced torsade de pointes.
-
•
Monitor electrolytes: Keep K >4.5, Mg>2.2
-
•
VT: Amiodarone 150 mg bolus then infusion 1 mg/min if QTc<450 ms (300 mg IV if code); Avoid amiodarone if QTc markedly prolonged.
-
•
VT: Lidocaine if QTc>550 ms: bolus 75–100 mg then infusion 0.5–2 mg/min, avoid if poor hepatic function or severe heart failure
-
•
Discuss antiarrhythmic drug choice if QTc borderline (450–550 msec) with cardiology/EP.
-
•
TdP/polymorphic VT: Maintain heart rate of >80 bpm (may need beta agonist such as dobutamine, isoproterenol or epinephrine; transvenous pacing).
-
•
Magnesium IV 2–4 gm for Torsade de Pointes
-
•
Limited bedside Echo for LV dysfunction evaluation.
-
•
Non-sustained polymorphic VT requires immediate patient assessment as cardiac arrest may follow.
|
| SVT including AF/AFL with heart rate > 150 bpm |
-
•
ACLS protocol if haemodynamically unstable.
-
•
Lenient rate control, allow permissive tachycardia.
-
•
SVT: Adenosine 6–12 mg IV push in acute management
-
•
SVT, AF/AFL: beta blocker may be preferred over calcium channel blocker depending on LV function
-
•
AF: if rhythm control desired, may use amiodarone.
-
•
Cardiology or EP consult before considering class Ic antiarrhythmics (flecainide, propafenone)
-
•
Discuss with cardiology if QTc>450 ms on a QT prolonging drug or QTc>500 ms or QTc increase after started on a QT prolonging drug.
-
•
Assess interaction of oral anticoagulant with antivirals.
|
| Bradycardia |
-
•
Follow standard bradycardia guidelines (AHA, ACLS) if patient unstable.
-
•
Discontinue AV nodal blocking agents.
-
•
Assess medication interaction with antivirals (Table 5).
|
