Management of HF in COVID-19 infection is a complex process. The algorithm starts from better fluid status assessment and monitoring vital signs. This can be performed noninvasively either by careful clinical exam, inferior vena cava (IVC) diameter/collapsibility measurement, and E/e’ assessment or invasively by hemodynamic assessment by pulmonary artery catheter. Patients with HF and COVID-19 are at higher risk of hypotension, which is why judicious use of diuretics and fluids should be guided by objective findings.
Use of diuretics to achieve euvolemia is key, but the dose should be adjusted to avoid dehydration. Concomitant sepsis and gastrointestinal (GI) bleeding should be considered to avoid hypoperfusion. Use of nonsteroidal anti-inflammatory drugs (NSAIDs) should be avoided to prevent kidney injury in combination with diuretics.
SARS-CoV-2 invades the lung cells by binding to angiotensin-converting enzyme 2 (ACE2) and can affect angiotensin levels in the tissue. It has been hypothesized that the use of angiotensin-converting enzyme inhibition (ACE-I) can interfere with the angiotensin levels, upregulating ACE2 and worsening COVID-19 infection in patients on ACE-I/angiotensin receptive blockers (ARBs). Several observational studies have indicated that ACE-I/ARBs have no role in the worsening of COVID-19 disease and may be protective at later stages of the disease. Thus, ACE-I/ARB/angiotensin receptor-neprilysin inhibitor (ARNI) should not be withheld in patients with COVID-19 infection and efforts to avoid hypotension should be made. In fact, the dose can be reduced if persistent hypotension is expected to avoid renal complications.
Although beta blockers have been considered as a standard-of-care treatment in HF, care should be taken in patients with COVID-19 infection. Because fever and tachycardia are commonly observed in these patients, special attention should be paid to avoid suppression of physiologic response and the dose of beta blocker should be adjusted based on hemodynamic assessment. Another aspect of treatment is the use of antiviral agents, such as darunavir. These agents may cause hypotension and bradycardia, so the dose of beta blockers can be reduced. Carvedilol has been hypothesized to have an anti-cytokine role, which needs to be validated.
Although the data regarding continuation of mineralocorticoid receptor antagonist (MRA) in HF patients with COVID-19 infection is limited, the general consensus is to avoid its use in the setting of renal complications and electrolyte abnormalities.
COVID-19-Specific Drugs and HF Medications
Use of antiviral medications, azithromycin, and hydroxychloroquine should be monitored, especially in view of drug-drug interactions. Prolonged QTc can lead to sudden cardiac death. Care should be taken specifically when patients are using antiarrhythmic and anticoagulation medications to avoid complications.
Patients with HF and COVID-19 infection are at higher risk of hypoxia due to lung injury and pulmonary edema. Use of noninvasive ventilation and prone positioning can be utilized to alleviate the work of breathing in pulmonary edema, but care should be taken in concomitant ARDS to avoid further lung injury. Hence, early intubation and mechanical ventilation should be carried out promptly with lung-protective strategies.
Use of inotropes and vasopressors should be guided by appropriate hemodynamic assessment. There are no data regarding the use of inodilators in the setting of COVID-19 infection; hence, they can be used on case-by-case basis.
Mechanical Circulatory Support Devices
Veno-venous-extracorporeal membrane oxygenation (V-V ECMO) can be utilized in the setting of persistent hypoxemia despite mechanical ventilation. Intra-aortic balloon pump (IABP) and an Impella heart pump can be utilized in the setting of cardiogenic shock.
Limited data have shown that patients with COVID-19 infection are at high risk for development of HFpEF in the long term.2 This is due to the inflammation-related cardiac fibrosis that may lead to diastolic dysfunction and pulmonary hypertension. Management strategies remain similar, but care should be sought to control hypertension and other risk factors to prevent disease progression (Figure 4-1).
Management algorithm of heart failure and COVID.