Table 1.
Summary of clinical investigations recommended in suspected/positive COVID-19 cases.
| CSANZ | ESC [5,11,12] | AHA/ACC/ASE/SCAI | Suggested Approach | |
|---|---|---|---|---|
| Bedside Tests | ||||
| High-sensitivity troponin | On admission and daily if elevated [8] as screening for suspected myocarditis and acute HF. | Not routine. Suspected type 1 MI or LV dysfunction. |
Routine if suspected cardiac involvement [61]. Only if MI clinically suspected [43]. |
Measure for suspected acute coronary syndrome, new HF or LV dysfunction, and in suspected cases of myocarditis. |
| B-type natriuretic peptide | Consider adjunctive [8]. | Only when HF is suspected on clinical grounds. | If HF suspected suspected [43]. | Measure for cases of suspected HF. |
| Electrocardiogram | On admission and repeat second daily if troponin elevated [8,10]. | Critically ill patients or in clinically indicated cases. On QT-prolonging drugs. |
Routine if suspected cardiac involvement [61]. | Perform in symptomatic patients requiring hospital admission, those with cardiovascular disease and those in whom QT-prolonging drugs are to be used. |
| Continuous cardiac monitoring (telemetry) | Elevated troponin [8] or at risk of QT prolongation [10]. | If QTc prolonged ≥500 ms or increased by ≥60 ms on QT prolonging medication. Febrile Brugada Syndrome patients. |
In those at risk of clinical deterioration, cardiovascular risk factors or on essential QTc prolonging medications [47]. Consider use of mobile telemetry units. |
Monitor those at risk of arrhythmia, including LV dysfunction, HF, myocarditis, MI. |
| Non-Invasive Imaging | ||||
| Chest X-ray | On admission [8]. | Heart failure cases. | Routine if suspected cardiac involvement [61]. | Hospitalised symptomatic patients. |
| Echocardiography | Suspicion of heart failure/myocarditis, significant arrhythmias, significant ECG changes, haemodynamic instability, previous heart disease with shock, prior to extracorporeal membrane oxygenation, rising troponin over 3 days, significant pericardial effusion [8,9]. Targeted study using POCUS where appropriate. |
Significantly elevated troponin (>5 x ULN) and not consistent with MI, acute HF/shock, significantly elevated BNP, malignant ventricular arrhythmia. Targeted study using POCUS where appropriate. |
Restrict unless expected to affect outcome [53]. Targeted study (consider POCUS) as first line. Follow up study recommended at 2-6 months for those with LV dysfunction during the acute phase [61]. |
Indicated in suspected HF or myocarditis, significant arrhythmias or ECG changes, more than mild pericardial effusion on chest CT, haemodynamic instability or previous heart disease with shock. Consider POCUS as first-line imaging modality. |
| Cardiac magnetic resonance imaging | Not recommended in COVID-19 [8]. Consider in myocarditis post mRNA vaccine as guided by cardiologist [38]. |
Suspected acute myocarditis with clinical signs or symptoms not explained by other diagnostic tools. | Consider in myocarditis or stress cardiomyopathy in new LV dysfunction with non-dilated LV and a non-coronary distribution of wall motion abnormalities, with no known cardiomyopathy. Useful for MINOCA [61]. |
Avoid in COVID-19. Reasonable to confirm myocarditis associated with mRNA vaccination in those with significantly elevated troponin elevation or ECG changes. LGE may inform risk of arrhythmia. |
| Interventional Procedures | ||||
| Angiography (including CT coronary angiography) | STEMI when angiography determines outcome. Consider fibrinolysis where appropriate. Delay in stable NSTEACS, consider angiography for very high-risk or unstable cases. CT coronary angiography can be considered for select patients [6]. |
STEMI indication. Consider in cardiogenic shock. Angiography <24 hrs in very high-risk NSTEACS. Await two negative swab results within 48 hrs and no clinical suspicion of COVID-19 for other cases. Consider as may expedite risk stratification and facilitate early discharge. Use COVID-19 dedicated laboratory. |
Primary PCI should remain standard of care for STEMI or very high-risk NSTEACS in PCI-capable centres [62]. Fibrinolysis may be preferable for STEMI in stable patients [63] non-PCI capable centres [62]. Delay angiography in stable NSTEACS [62,63] Consider CT coronary angiography [61]. |
Perform in STEMI where angiography will significantly alter outcome. Consider fibrinolysis in appropriately selected patients. Defer in NSTEACS if no high-risk features. |
| Pericardiocentesis | No formal recommendation. | No formal indications. Consider bedside procedure where possible. |
No formal recommendation. | Indicated for treatment of tamponade where appropriate, where expectant management is likely to result in preventable poor outcome. |
| Myocardial biopsy | Not recommended [8]. | Not routinely recommended. Consider in refractory or severe heart failure if determines management. | No formal recommendation. | Not recommended to confirm myocarditis. |
| Elective echocardiography, angiography and electrophysiology studies | Delay or postpone in stable patients based on clinical urgency and triage system [6,7,9,10]. | Avoid elective procedures. | Defer in/outpatient investigations and procedures for stable patients [62,63]. | Deferral of elective procedures as per local policy. |
Abbreviations: CSANZ, Cardiac Society of Australia and New Zealand; ESC, European Society of Cardiology; AHA, American Heart Association; ACC, American College of Cardiology; ASE, American Society of Echocardiography; SCAI, Society for Cardiovascular Angiography and Interventions; MI, myocardial infarction; LV, left ventricular; HF, heart failure; ECG, electrocardiogram; POCUS, point-of-care ultrasound; BNP, brain natriuretic peptide; CT, computed tomography; MINOCA, myocardial infarction with non-obstructive coronary arteries; LGE, late gadolinium enhancement; STEMI, ST-elevation myocardial infarction; NSTEACs, non-ST elevation acute coronary syndromes; PCI, percutaneous coronary intervention.