Is a systolic blood pressure of 100-120 mmHg a normal target for patients post-Coronary Artery Bypass Graft (CABG) with a history of myocarditis induced by COVID-19?

Target Blood Pressure for Post-CABG Patients with COVID-19-Induced Myocarditis

A systolic blood pressure of 100-120 mmHg is an appropriate target range for patients post-CABG with a history of COVID-19-induced myocarditis to balance adequate organ perfusion while avoiding excessive cardiac workload. 1

Pathophysiology Considerations

• COVID-19 infection can cause significant cardiovascular complications, including myocarditis, which may persist beyond the acute infection phase 1
• SARS-CoV-2 affects the renin-angiotensin system (RAS) through binding to ACE2 receptors, potentially leading to RAS dysregulation and blood pressure alterations 1
• Loss of pulmonary endothelial ACE2 due to viral binding can lead to increased circulating angiotensin II, potentially causing vasoconstriction and increased blood pressure 1
• Approximately 20-30% of hospitalized COVID-19 patients develop acute cardiac injury that may be related to direct myocardial injury or secondary hyperinflammatory responses 1

Blood Pressure Management in Post-CABG with COVID-19 Myocarditis

• While hypotension can occur in severely ill COVID-19 patients, it is uncommon at presentation; some reports suggest blood pressure at presentation might be higher in patients who develop more severe COVID-19 1
• For post-CABG patients with COVID-19-induced myocarditis, maintaining adequate coronary perfusion pressure is essential while avoiding excessive afterload that could stress the healing myocardium 1
• The target systolic BP of 100-120 mmHg provides a balance between:
  • Ensuring adequate organ perfusion (avoiding hypotension) 1
  • Preventing excessive cardiac workload that could worsen myocardial recovery 1

Monitoring and Management Recommendations

• Close monitoring of circulatory parameters and cardiac biomarkers is essential in these patients 1
• Heart and lung ultrasound should be used for clinical evaluation, with comprehensive echocardiography for patients with suspected cardiac involvement 1
• For patients with elevated cardiac troponins, ECG abnormalities, or echocardiographic abnormalities concerning for myocarditis, cardiology consultation is recommended 1
• Beta-blockers may be considered for heart rate management, but should be used cautiously as they can precipitate cardiogenic shock in patients with compromised cardiac function 1, 2

Special Considerations

• If hemodynamic instability persists despite maximal medical therapy, escalation to percutaneous ventricular assist devices should be considered 1
• For patients with evidence of myocarditis, strenuous physical activity should be avoided for 3-6 months 1
• Follow-up surveillance testing (ECG, echocardiogram, ambulatory rhythm monitor, cardiac MRI) is helpful to gauge recovery of cardiac function and inflammation 1

Potential Pitfalls

• Avoid excessive hypotension (<100 mmHg systolic) as it may compromise coronary perfusion and organ function, particularly in post-CABG patients 1
• Conversely, higher blood pressures (>120 mmHg systolic) may increase myocardial oxygen demand and workload, potentially worsening recovery from myocarditis 1
• Be vigilant for signs of cardiogenic shock, which may occur in patients with COVID-19-related myocarditis and require prompt intervention 1