What is the recommended treatment for patients with Covid-19 (Coronavirus disease 2019) infection and associated cardiomyopathy?

Management of COVID-19 Associated Cardiomyopathy

For patients with COVID-19 and cardiomyopathy, continue all guideline-directed medical therapy including ACE inhibitors/ARBs and beta-blockers, initiate standard heart failure treatment protocols, and avoid routine dual antiplatelet therapy unless acute coronary syndrome is confirmed. 1

Continuation of Cardiovascular Medications

The most critical decision is to maintain all existing cardiovascular medications during COVID-19 infection. 1

• Continue ACE inhibitors and ARBs without interruption in all patients with established indications, as large multicenter studies demonstrate no increased risk of infection or mortality, and these agents may be protective against ICU admission and death. 1, 2
• Continue beta-blockers (such as metoprolol or carvedilol) at current doses for patients with pre-existing cardiomyopathy or heart failure. 1, 3
• Continue aldosterone antagonists (spironolactone) for volume management and heart failure treatment. 3, 4
• Continue statins in all patients already on therapy, as they should not be withdrawn during COVID-19 infection. 1, 3

Distinguishing Cardiomyopathy Etiology

Differentiate between true acute coronary syndrome, myocarditis, stress cardiomyopathy, and Type 2 myocardial injury before initiating invasive interventions. 1, 5

• Elevated troponins alone do not indicate acute coronary syndrome and are common in COVID-19 (7-41% of hospitalized patients) due to myocardial injury, myocarditis, stress cardiomyopathy, or direct viral injury. 1, 6
• Obtain cardiac MRI in hemodynamically stable patients to confirm myocarditis diagnosis and assess extent of ventricular dysfunction and inflammation. 7, 4
• Perform echocardiogram with global longitudinal strain to evaluate left ventricular function and distinguish between different cardiomyopathy etiologies. 7, 4
• Check ECG, cardiac troponin, BNP/NT-proBNP, and C-reactive protein as initial testing for suspected cardiac involvement. 7, 4

Treatment Based on Specific Presentation

For COVID-19 with Myocarditis:

• Hospitalize at an advanced heart failure center for patients with definite myocarditis that is mild or moderate in severity. 4
• Initiate guideline-directed medical therapy for heart failure including ACE inhibitors/ARBs, beta-blockers (if hemodynamically stable), and aldosterone antagonists at low doses. 4
• Administer corticosteroids (methylprednisolone 1000 mg/day followed by oral prednisone 1 mg/kg/day) for patients with myocarditis and COVID-19 pneumonia requiring supplemental oxygen, continuing until resolution of symptoms and normalization of troponin. 1, 4
• Consider mechanical circulatory support for patients developing cardiogenic shock despite optimal medical management. 4
• Avoid NSAIDs unless documented pericardial involvement exists, given risk of increased inflammation and mortality in isolated myocarditis. 7, 4

For COVID-19 with Heart Failure/Cardiomyopathy:

• Add SGLT2 inhibitor (dapagliflozin or empagliflozin) regardless of diabetes status, as these reduce heart failure hospitalizations and cardiovascular death. 3
• Optimize diuretic therapy with furosemide and spironolactone based on volume status and daily weights. 3
• Titrate ACE inhibitor/ARB (lisinopril or losartan) once blood pressure tolerates, as foundational therapy for heart failure. 3

For COVID-19 with Acute Coronary Syndrome:

• Initiate dual antiplatelet therapy (aspirin plus P2Y12 inhibitor: prasugrel or ticagrelor preferentially, or clopidogrel if high bleeding risk) for 12 months in patients with confirmed ACS. 1
• Do NOT initiate DAPT for myocardial injury without confirmed ACS, as elevated troponins do not justify antiplatelet therapy and increase bleeding risk. 1
• Consider fibrinolytic therapy for relatively stable STEMI patients with suspected or known COVID-19 if primary PCI resources are limited. 5
• Perform primary PCI if definite STEMI and personal protective equipment is available with adequate infection control in the catheterization laboratory. 5

Anticoagulation Management

Stratify anticoagulation intensity based on illness severity and existing indications. 1

• Continue therapeutic anticoagulation (rivaroxaban, apixaban, warfarin) at current doses for patients with atrial fibrillation or prior thromboembolism. 3, 8
• Add prophylactic-dose LMWH for hospitalized non-ICU patients not on therapeutic anticoagulation. 1
• Consider therapeutic-dose anticoagulation with heparin for noncritically ill hospitalized patients, as this increases probability of survival to discharge with reduced organ support compared to prophylactic dosing. 1
• Use prophylactic-dose LMWH only for critically ill ICU patients, as therapeutic anticoagulation did not improve outcomes in this population. 1
• Extend thromboprophylaxis with rivaroxaban 10 mg daily for 35 days post-hospitalization in high-risk patients to improve clinical outcomes. 8

Monitoring and Follow-Up

Implement structured cardiovascular surveillance at specific intervals post-infection. 7, 3, 4

• Schedule follow-up ECG, echocardiogram, and ambulatory rhythm monitor at 3-6 months post-infection to assess for persistent cardiac dysfunction or arrhythmias. 7, 3, 4
• Obtain cardiac MRI at 3-6 months if symptoms persist or worsen, particularly if concern for ongoing myocardial inflammation. 7, 3
• Monitor inflammatory markers (ferritin, CRP, D-dimer, IL-6) every 3 months until normalization. 7
• Restrict competitive sports for 3-6 months after myocarditis diagnosis. 4

Critical Pitfalls to Avoid

• Never withdraw ACE inhibitors/ARBs based on theoretical concerns about ACE2 upregulation, as evidence shows protective effects. 1, 2, 9
• Never initiate DAPT for elevated troponins alone without confirmed ACS, as this increases bleeding risk without benefit. 1
• Never use therapeutic anticoagulation in critically ill ICU patients unless specific thrombotic indication exists, as prophylactic dosing is superior. 1
• Never assume elevated troponins indicate ACS in COVID-19 patients; differentiate from myocarditis and Type 2 MI before invasive procedures. 1, 5
• Monitor QT interval closely if using any QT-prolonging medications, though hydroxychloroquine emergency authorization has been revoked. 1, 5